Download Sleeve Gastrectomy as a Surgical Tool for the Treatment of Obesity

TOPIC SELECTION
Obesity has always been a fascinating subject to me. I have never been overweight nor have any of my
family members been overweight. Therefore, I cannot relate to someone who is obese, however, I can
empathize with his/her situation. I understand that it is not simply a matter of lacking self-control or
being lazy. Obesity is a disease state just like cancer or diabetes, requiring a multidisciplinary approach
to treatment.
I couldn’t quite understand why obese individuals would choose to have major surgery when behavior
and dietary habits need to be changed anyway. Why can’t they just change behaviors before hand and
avoid surgery? By choosing to research a bariatric procedure, I had hoped to gain an understanding of
this.
The main reason I went back to school to be a registered dietitian was to work with the obese
population. I originally wanted to become a weight management counselor at a local health club but
have gained more and more interest in bariatrics. Part of why I chose this case study topic was to learn
more about bariatric surgical procedures and to see if this truly is something I would like to specialize in
(and it is).
INTRODUCTION
According to a recent study performed by the CDC, 34% of adults in the United States, aged 20 and over,
were found to be obese in 2005-2006. This amounts to approximately 72 million Americans (1). What’s
even more alarming than this is the global reach of obesity. In 2005, the World Health Organization
(WHO) estimated that there were at least 400 million obese adults throughout the world and WHO
further predicts that this number will jump to at least 700 million by the year 2015 (2). Obesity is no
longer a disease seen only in industrialized nations. It is now prevalent in underdeveloped countries,
especially in urban areas (3,2).
Obesity is a very complex disease that still is not fully understood. What we do know is that obesity is
influenced by many factors including environmental, biological, psychological, cultural, socioeconomic
and genetic factors (4,5,6). It is a chronic disease associated with morbidity and mortality. The Centers
for Disease Control (CDC), reports that there are approximately 400,000 deaths per year attributable to
obesity related conditions (7).
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There are several treatment options for obesity including behavior modification, diet therapy, exercise
therapy, pharmacotherapy and bariatric surgery. Most non-surgical weight loss programs have proven
ineffective at sustaining long-term weight loss (8,9).
A recent systemic review of nonsurgical weight
loss programs revealed high costs, attrition rates, and the probability of regaining at least 50% of the
lost weight in 1 to 2 years (9). Research shows that bariatric surgery is the only effective treatment for
morbid obesity and can result in improvement or complete resolution of obesity related co-morbidities
(10,11,12).
There are three types of bariatric surgical procedures:
restrictive, malabsorptive and combined
(restrictive and malabsorptive). Sleeve gastrectomy (SG) is a restrictive procedure that removes a large
portion of the stomach, leaving a “sleeve” of a stomach that holds 2-3 ounces (13). Because there is no
malabsorption involved, and the stomach functions normally, there are rarely any nutritional
deficiencies and complications are minimized (14). Through the use of laparoscopic surgery, incisions
are smaller, recovery time is quicker and hospital stay is reduced. SG was originally the first step in a
two-stage procedure for the super-obese but has recently gained popularity among surgeons as a standalone procedure (15). Short-term studies of excess weight loss show promising results, however, there
are no long-term studies to indicate efficacy beyond three years (16).
WHAT IS OBESITY AND HOW IS IT DEFINED?
As defined by WHO, obesity is an “abnormal or excessive fat accumulation that may impair health” (2).
Excessive fat accumulation is the result of an imbalance between energy intake and energy expenditure
(17). Excess energy is stored in fat cells of adipose tissue. As long as energy intake continues to exceed
energy output, fat cells will grow in size. This is known as hypertrophic obesity (3). Fat cells are capable
of expanding as much as 1,000 times (18). Once fat cells reach their maximum storage capacity, new fat
cells are generated.
This is known as hyperplasia obesity. (If an individual loses weight, he/she can
reduce the size of the fat cells but cannot reduce the number of fat cells (3).
Clinically, an individual is considered to be obese if he or she has a Body Mass Index (BMI) greater than
or equal to 30 (19). BMI is a non-gender-specific measurement of a person’s weight in relation to height
and is correlated with body fatness (3,17,20). Although it does not directly measure body fat
percentage, it is a better marker of obesity than weight itself. BMI can be used to assess an individual’s
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health risks associated with overweight and obesity; as BMI increases, health risks tend to increase (20).
The National Institutes of Health (NIH) established the following guidelines to classify obesity (19):
Table 1. NIH Classification of Overweight and Obesity
CLASSIFICATION
Underweight
Normal
Overweight
Obesity, class I
Obesity, class II
Extreme obesity, class III
BMI kg/m2
<18.5
18.5-24.9
25.0-29.9
30.0-34.99
35.0-39.9
>= 40
The location of fat on the body is also of great concern. Women typically collect fat in their hips and
buttocks, giving them a “pear” shape, called gynoid obesity. Men usually build up fat around their
bellies, giving them more of an “apple” shape, called central, abdominal or android obesity (14). Excess
abdominal fat is an important, independent risk factor for disease. Research has shown that waist
circumference is directly associated with abdominal fat and can be used in the assessment of the risks
associated with obesity or overweight. If you carry fat mainly around your waist (central/abdominal
fat), you are more likely to develop obesity related health problems (15). Central obesity is closely
associated with heart disease, stroke, diabetes, hypertension, and some types of cancer (3). Women
with a waist measurement of more than 35 inches and men with a waist measurement of more than 40
inches may have more health risks than people with lower waist measurements because of their body
fat distribution (21).
WHO ARE THE OBESE?
Obesity has increased in men and women of all ages, races and ethnicity in the United States (Figure 1).
However, minority populations experience the greatest prevalence of obesity (22). This appears to be
the result of lower levels of education and income (17). Prevalence of obesity is higher among women
than men. The oxidation of basal fat (the rate at which fat is broken down) is lower in women than men
which could be a contributing factor to the higher incidence of obesity among women (3). 23% of white
women, 31% of Hispanic women, and 37% of Black women are obese (22). Metabolic rates are lower in
black women as opposed to white women, which could explain their increased prevalence of obesity
(23). The prevalence of overweight and obesity in elderly adults in the US is high. 75% of men and 66%
of women aged 60 or above are overweight or obese (24).
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Figure 1. Source: Center for Disease Control (25)
CAUSES OF OBESITY
Simplistically, obesity is caused by an energy imbalance in which energy intake exceeds energy
expenditure. For every 3500 kilocalories (kcals) consumed above individual needs, one pound of fat is
created and stored in adipose and muscle tissue through the actions of the enzyme lipoprotein lipase
(LPL). LPL activity in fat cells of obese individuals is higher than leaner individuals. As a result, even
small increases in excessive intake results in greater storage of fat (3). This leads to hypertrophy and
hyperplasia of fat cells.
Unfortunately, obesity is much more complex than this. There are various influencing factors leading to
excessive energy intake and limited or no energy expenditure.
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Environment
The evolution of humans created a biological adaptive response to starvation as a protective mechanism
of body fat in times of energy scarcity (26). Hunters and gatherers of years long ago had a labor
intensive existence. As time went on, technological advances were made that reduced the amount of
manual work required for daily activities. The advent of industrialization paved the way for the
proliferation of food availability, fast and convenience foods and energy-saving devices experienced
today (22,26). Our biological response to store excess body fat is no longer essential for survival in
modern-day society. Ironically, it is now counterintuitive to survival as high-calorie foods and inactivity
lead to obesity and its associated diseases. The authors of Handbook of Obesity Treatment summed it
up best: “biology permits obesity to occur in individuals, but the environment causes obesity in the
culture (27).”
Obesity prevalence has increased along with the changes in our food supply (17). We have seen a surge
in high-fat and/or high-calorie snacks, meals, and beverages as well as larger portion sizes. This change
does not support healthy eating habits (21). According to the surgeon general, only 3% of people in the
US meet four out of five recommendations for intake of grains, fruit, vegetables, dairy products and
meats (6). Food security and efficiency in food production has evolved at the cost of overall declining
nutritional health (26).
Over the last twenty years, portion sizes have increased significantly (Table 2). A typical hamburger in
1957 weighed 1oz and provided 210 kcals. Today, that same hamburger weighs 6oz and provides 618
kcals. Studies have shown that when people are given larger portions, they eat more. Compared to the
1970’s, average daily food intake has increased by at least 200 kcals per day (28). Assuming energy
expenditure does not exceed intake that would lead to a twenty pound weight gain over the course of
one year.
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Table 2. Portion Comparison
20 Years Ago
Additional Calories
Consumed
Today
Portion
Calories Portion
Calories
Hamburger
1 ounce
210
6 ounces
618
408
Bagel
3'' diameter
140
6'' diameter
350
210
Spaghetti
w/meatballs
1 cup sauce
500
3 sm meatballs
2 cups sauce 1,020
3 lg meatballs
520
Soda
6.5 ounces
82
20 ounces
250
168
Blueberry
muffin
1.5 ounces
210
5 ounces
500
290
Source: adapted from: http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan/learn-it/distortion.htm
The average American consumes over 3500 kcals per day (8). Most consumers have no idea how many
calories they are actually consuming each day. It is very difficult to keep track when portion sizes are
larger than recommended serving sizes.
For example, a dinner at the Macaroni Grill could cost you
3,330 kcals (Table 3). Based on a 2,000 calorie diet, this is approximately 65% more than daily needs in
just one meal!
Table 3. Dinner at Macaroni Grill
ITEM
CALORIES
1 bowl pasta fagioli soup (appetizer)
760
Penne with oven roasted chicken (main entrée)
1330
Tiramisu (dessert)
1000
20 oz soda
240
Source: http://www.calorie-count.com/calories/manufacturer/1577.html
There has been a shift in the types of beverages consumed. Our ancestors relied on two sources, water
and breast milk. Today, there are numerous beverages on the market containing high-fructose corn
syrup which have little or no nutritive value. These sweetened high-calorie beverages are partly
responsible for the rise in obesity. Studies have shown consumption of these beverages do not reduce
the amount of calories consumed from food in proportion to the amount of calories consumed from
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beverages. In addition, intake of high-calorie beverages is actually increased as the portion size of food
eaten is increased. Carbohydrates, the major component in sweetened beverages, do not stimulate as
many “satiety factors” as fat or protein. One theory to explain this is that our evolutionary physiological
adaptation to water and breast milk has made it difficult to process the carbohydrates found in
beverages (29).
Modern society has changed the types of foods we eat, how much we eat and where we eat. Fat in
foods, which is characteristic of the American diet, increases the palatability of food. It is easy to overeat fatty food items because they do not produce the same feeling of satiety that carbohydrate rich
foods do. Fats are easily hidden in foods. Calories can add up very quickly as calories derived from fat
are denser than calories derived from protein or carbohydrates sources (30).
Table 4. Caloric Value of Macronutrients
Nutrient
Calories/gram
Carbohydrate
4
Protein
4
Fat
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Many convenience food items are hydrogenated to preserve freshness. Foods that are hydrogenated
contain trans-fatty acids (TFA). TFA’s are also found in hydrogenated vegetable oils used to fry many
fast food items. The risk of weight gain increases with high intakes of TFA’s, possibly by producing a
biological effect that promotes abdominal obesity (31).
Food is available almost anywhere you go, not just in supermarkets or restaurants.
In today’s
competitive market, drug stores contain a full line of groceries. Even video stores sell candy, chips and
beverages. Vending machines provide easy access to calorie dense drinks and snacks, which can be
found just about anywhere: in schools, gas stations, office buildings, airports, and hotels. Several fast
food restaurants, diners and supermarkets are open 24 hours a day. It’s no wonder that the average
weight gain in the US is .5-1.0 kg/year (5).
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A greater percentage of meals are now eaten or purchased outside of the home. Since the 1960’s, it has
been reported that American households doubled their food budget spent on restaurant meals (8).
These meals are generally rich in fat and simple carbohydrates which contribute to weight gain. Dietary
fat is efficiently converted to body fat (17) and excess energy from carbohydrates leads to weight gain
by suppressing fat oxidation (the break-down of fat) (18).
Technology has created a very sedentary society. Cars, computers, television and video games all help
to contribute to our “couch potato” lifestyles. Today, more people drive long distances to work instead
of walking (21). And once at work, people may spend 8-12 hours a day in front of a computer screen. If
people are not exercising daily to make up for sedentary behaviors, energy intake will be greater than
energy expenditure, which will lead to weight gain over an extended period of time.
Biology
There are approximately 40 hormones that have been found to play a role in the regulation of intake
and body weight (Appendix A). For the purpose of this paper, I will focus on two of the major regulators,
leptin and ghrelin.
Leptin is a protein that has been discovered to play a role in the regulation of intake and body weight
(28). It acts like a hormone by signaling the brain to decrease food intake when energy stores are filled.
Adipose tissue releases leptin into the circulatory system in response to energy stores. Leptin then
travels through the blood brain barrier and into the brain, creating a feedback mechanism to suppress
appetite and increase energy expenditure. As weight gain and body fat increase, leptin levels increase
(3,28). Obese individuals tend to have high levels of leptin (3). So why don’t they lose weight?
Researchers believe that obese people experience leptin sensitivity similar to that of a diabetic
experiencing insulin sensitivity. It is postulated that leptin levels rise to compensate for this sensitivity
(17).
Ghrelin is also a protein that acts like a hormone, playing a role in the regulation of intake and body
weight.
However, ghrelin acts in opposition to leptin by stimulating appetite and decreasing energy
expenditure (3,17). Lack of sleep produces ghrelin, which stimulates appetite and creates less leptin,
which in turn, also increases appetite (32). Obese individuals may have trouble getting a good night’s
sleep due to sleep apnea. Ghrelin levels are higher in females than males which may help explain why
the prevalence of obesity is higher among females. A decrease in plasma ghrelin levels is seen post
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gastrectomy (28).
This gives an advantage to patients undergoing bariatric surgery involving
gastrectomy.
Socioeconomics
Level of education and income play a role in the prevalence of obesity. Obesity rates are highest among
those of a lower socioeconomic class. Low-income individuals are associated with lower levels of
education. Knowledge of nutrition is inadequate. People are unaware of the harm they are doing to
themselves with high-fat, high-calorie diets (they are likely not even aware of how many calories or
grams of fat are in the foods they eat). Low-income families are at a disadvantage because they do not
have the financial means to purchase gym memberships or healthy food items. It is often cheaper to
purchase and prepare processed foods (21). Low-income families are more likely to take advantage of
“supersizing” fast food items because it appears to be a better value financially. Access to nutritious
food may not be available.
Families may depend on the “corner store” for groceries because
supermarkets are not within walking distance. “Corner stores” do not carry an array of nutritious foods.
They mainly stock convenience food items that are high in fat and calories.
The type of neighborhood you live in may contribute to the development of obesity. Neighborhoods
can be without sidewalks, parks, recreational facilities, after-school programs, and community centers,
making it difficult to achieve an optimum level of physical activity (21). Unsafe neighborhoods may
force residents to stay inside as often as possible, limiting their mobility and energy expenditure.
Psychology
Individual behaviors can lead to the development of obesity. Binge eating is a reported problem in 30%
of obese individuals seeking treatment (17). It is often used as a coping mechanism for stress or
depression. Binge eating disorder (BED) is characterized by the consumption of large amounts of food in
a discrete period of time where the individual feels he/she has no control over eating during the episode
(17). It is not associated with any other behaviors such as purging, fasting , or excessive exercise. Other
behaviors that can lead to overeating and obesity are:
 Eating when you’re bored, nervous or not hungry
 Eating while watching television
 “Super-sizing” meals
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 “Cleaning your plate” at every meal
 Skipping breakfast
 Fad / restrictive diets
 Consuming high caloric beverages and/or snacks
 Not getting enough sleep
 Substituting food for other addictions (i.e. smoking)
 Intake of energy-dense, nutrient poor foods (18)
Certain drugs used to treat depression, psychiatric conditions and seizures can cause weight gain by
increasing appetite, causing fluid retention or lowering metabolic rate (Table 5) (15). Tricyclic and
heterocyclic antidepressants may increase appetite and cravings for carbohydrates and sweets. These
drugs can also cause side effects such as dry mouth and increased thirst which may cause an individual
to seek relief from soft drinks and hard candy. Long-term use of steroids may lead to weight gain as well
(17).
Table 5. Drugs Associated with Weight Gain
Antidiabetes agents
o
Insulin
o
Sulfonylureas
o
Thiazolodinediones
Antihistamines
o
Cyproheptidine
Antihypertensive agents
o
Beta adrenergic blockers (proprandolol)
o
Alpha-1 adrenergic blockers (terazosin)
Psychiatric/neurological agents
o
Antipsychotic agents

Thioridazine

Olanzapine
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(Table 5. Drugs Associated with weight gain cont’d)

Clozapine

Risperidone

Quetiapine
o
Mood stabilizers – lithium
o
Antidepressants
o

Amitriptylinle

nortriptyline

imipramine

mitrazapine

monoamine oxidase inhibitors

paroxetine
Antiepileptic drugs

gabapentin

valporate

carbamazepine
Steroid hormones
o
Contraceptives
o
Glucocorticoids
o
Progestational steroids
Source: ADA’s Nutrition Care Manual (33)
Culture
If you ask most people whether they eat to live or live to eat, they will tell you the latter. Our culture is
centered on food.
Go into any office and you are bound to find a jar of candy. We have cake for
birthdays, assorted fat-laden appetizers and dessert for parties and holidays, buttered popcorn for
watching movies (jumbo size, of course), salty snacks for watching television, and the list goes on.
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People often eat out in celebration of a special occasion. Families no longer gather around the dinner
table the way they used to. Meals are eaten at the computer, in the living room while watching
television or at fast food restaurants. A majority of women now work outside of the home and do not
have time to cook a nutritious meal. It is easier to pick up dinner at a fast food restaurant; you don’t
have to shop, prep, cook or clean. Large portions have also become part of our culture. All of these
extra calories add up quickly and can contribute to obesity if we’re not careful.
Our current lifestyles are burdened with stress. Many Americans do not get the recommended number
of hours of sleep each night and are sleep deprived. Even if we do get to bed at a decent hour, we have
trouble sleeping because of stress. Although a causal link has not been found, sleep deprivation and
stress have been associated with obesity (26).
Genetics
Obesity tends to run in families, suggesting a genetic cause. However, families also share diet and
lifestyle habits that may contribute to obesity (21). Some people store more energy as fat in an
environment of excess; others lose less fat in an environment of scarcity. The different responses are
largely due to genetic variation between individuals (34). Separating genetic from other influences on
obesity is often difficult. Even so, science does show a link between obesity and heredity (21). Family
and twin studies have shown that genetic factors contribute 40-70% to the variation in common obesity
(36). However, genes are not destiny (34).
There are some genetic disorders that lead to obesity:
 Hypothyrodism – a condition in which the thyroid gland fails to produce enough thyroid
hormone. It often results in lowered metabolic rate, which can lead to weight gain (21).
 Cushing’s syndrome – a hormonal disorder caused by prolonged exposure of the body’s tissues
to high levels of the hormone cortisol. Symptoms vary, but most people have upper obesity,
rounded face, increased fat around the neck, and thinning arms and legs (21).
 Polycystic ovary syndrome (PCOS) – an endocrine disorder characterized by hyperandrogenism
and insulin resistance. Symptoms include irregular or missed menstrual cycles, multiple ovarian
cysts, infertility, acne, hair growth and hair loss. PCOS is closely associated with obesity, mainly
android obesity. People with PCOS often have eating disorders (18).
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 Praeder-Willi – a genetic disorder characterized by excessive appetite, massive obesity, short
stature, and often mental retardation (3).
HEALTH RISKS ASSOCIATED WITH OBESITY?
Obesity is associated with numerous medical conditions such as cardiovascular disease (CVD),
hypertension, pulmonary difficulties, certain types of cancers, chronic musculoskeletal problems,
infertility, conditions resulting from intraabdominal pressure, fatty liver disease and type II diabetes
(36,37). Data from NHANES III show that morbidity for a number of health conditions increases as BMI
increases in both men and women (38). The degree of obesity increases the severity of co-morbidities
(18). Some are debilitating and others can actually be life-threatening. According to the surgeon
general, individuals who are obese have a 50-100% increased risk of premature death from all causes
compared to normal weight individuals; and morbidity from obesity may be as great as from poverty,
smoking, or problem drinking (6).
Cardiovascular Disease (CVD)
The risk of death in the morbidly obese is increased fivefold from cardiovascular disease. The risk of
heart failure increases 5% for men and 7% for women with each increment of 1 kg/m2 in BMI (9).
Inflammation, which can be caused by substances produced by excess body fat, may raise heart disease
risk (39). Other obesity related risk factors contributing to heart disease are high blood pressure, high
levels of triglycerides and low-density lipoprotein (LDL), and low levels of high-density lipoprotein (HDL)
cholesterol (9). These risk factors, along with elevated blood glucose and central obesity, in combination
are known as the “metabolic syndrome.” The National Cholesterol Education Project Adult Treatment
Panel III has defined the metabolic syndrome as having at least three of the risk factors previously
noted. The metabolic syndrome is a strong risk factor for CVD (9). According to a publication by the
National Institute of health, a person with metabolic syndrome has approximately twice the risk factor
for coronary heart disease and it is estimated that 27% of American adults have the metabolic syndrome
(39).
The heart of a morbidly obese person is forced to work harder due to an increased circulating blood
volume that is associated with morbid obesity.
As the heart works harder, the cardiac muscle gets
larger. This causes structural changes leading to congestive heart failure which decreases the function
of the heart. Structural changes can also lead to arrhythmias. Obesity is associated with a 50% increase
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in the risk of developing atrial fibrillation secondary to left atrial enlargement (37). Structural and
functional changes may also be the result of fat infiltration of the heart (9). This can alter the
hemodynamic load or lead to metabolic abnormalities, inflammation or coronary artery disease.
Obesity also increases the risk of stroke and peripheral vascular disease (40).
Hypertension
Prospective studies have shown that obesity increases the risk of developing hypertension. In the
Framingham Offspring Study, 78% of cases of hypertension in men and 64% in women were attributable
to obesity (41). Hypertension is defined as a persistently high arterial blood pressure, where systolic
blood pressure is above 140 mm Hg or diastolic blood pressure is above 90 mm Hg (18). Because of the
American diet, obese individuals are more likely to have high cholesterol levels. When the body has
more cholesterol than it needs, cholesterol begins to build up and form plaque on artery walls,
narrowing the passage of blood flow. The heart has to work harder to circulate blood throughout the
body. This raises blood pressure, resulting in hypertension. Hypertension can also be caused pulmonary
dysfunction, another obesity related co-morbidity (42).
Pulmonary Dysfunction
Obesity may compromise pulmonary function in the following ways:
 Excess fat externally and internally compresses the thoracic cavity
 Fatty infiltration of accessory breathing muscles decrease compliance of chest wall
 Increased intraabdominal pressure causes cephalad displacement of diaphragm,
resulting in diminished lung volume and suboptimal pulmonary dynamics
 Increased pulmonary blood volume competes for space in chest cavity, further
decreasing lung volumes (42)
The functional issues listed above can lead to obstructive sleep apnea (OSA) and obesity hypoventilation
(37).
OSA is characterized by loud snoring, daytime sleepiness, and frequent night-time awakening.
While asleep, people with OSA stop breathing for short periods of time. This is caused by a collapsing
pharyngeal airway (43) from the pressure of fat around the neck when an individual lies down. The
prevalence of obstructive sleep apnea in morbidly obese patients is as high as 71% (37). OHS, commonly
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called the pickwickian syndrome, is defined as having a BMI greater than 30 kg/m2 and an awake PaCO2
greater than 45 mm Hg in the absence of a known cause for hypoventilation (42).
Reactive airways in response to the pro-inflammatory state present in obese individuals may lead to
asthma. Chronic aspiration associated with gastroesophageal reflux, a common condition among the
obese, may also lead to asthma by creating hypersensitive airways (42).
Cancer
Obesity is associated with several types of cancers including prostate, breast (postmenopausal),
esophageal, endometrial, colorectal, gall bladder and thyroid (in women) cancer (43). The surgeon
general reports that: “women who gain more than 20 pounds from age 18 to midlife, double their risk
of postmenopausal breast cancer, compared to women whose weight remains stable (44);” in women
with a BMI of 34 or greater, the risk of developing endometrial cancer is increased by more than six
times (6). The American Cancer Society found that in 2002, 51% of newly diagnosed cases of cancer
among women and approximately 14% of newly diagnosed cases among men were linked to obesity.
The etiologies are not fully understood. It is postulated that esophageal cancer arises from gastric
reflux, which is often experienced by obese individuals. Since studies have shown that physical activity
reduces the risk of colorectal cancer, it is hypothesized that physical inactivity, which is common among
the obese, increases risk.
Osteoarthritis
The excess weight of an obese individual increases the stress placed on joint bones and cartilage.
Overtime, the bone begins to wear down and cause pain due to the deterioration of cartilage which
protects the bone (21,39). This is evident in weight-bearing joints such as the knees, hips, spine and
ankles (37). According to the surgeon general, for every 2-pound increase in weight, the risk of
developing arthritis is increased by 9 to 13%.
The risk for osteoarthritis may be increased by
inflammation commonly found in obese individuals (39).
Reproductive Complications
Obesity can cause reproductive problems in women such as menstrual irregularities and infertility.
There are also several complications of pregnancy related to obesity. There is a higher risk of death for
the unborn baby and mother. The maternal blood pressure can increase by as much as 10 times. High
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blood pressure during pregnancy is called pre-eclampsia. If it is left untreated, it can cause severe
problems for the mother and baby. Obese women who are pregnant are likely to develop gestational
diabetes. Complications with labor and delivery are also increased. Infants born to obese women are at
higher risk for birth defects such as neural tube defects and spina bifida (45) stillbirth, prematurity and
being large for gestational age (39).
Conditions related to intraabominal Pressure
Intraabdominal pressure is caused by excessive abdominal girth (40). As pressure increases on the
surrounding abdominal organs, risk of various associated conditions increases. Gastroesophageal reflux
disease (GERD) is one such condition. When the lower esophageal sphincter does not close properly,
contents of the stomach may leak back into the esophagus often causing heartburn (GERD can also be
asymptomatic) (21). Overtime, GERD can erode the lining of the esophagus, causing a condition known
as Barrett’s esophagus, which could potentially, although rare, develop into esophageal
adenocarcinoma. There are several reasons why reflux may occur: a reduced lower esophageal
sphincter (LES) pressure, increased frequency of transient LES relaxations, esophageal and gastric
motility disorders or the presence of a hiatal hernia. Symptoms of GERD are more common in obese
individuals than lean individuals (40).
Other conditions associated with intraabdominal pressure are:
 Stress overflow urinary incontinence
 Venous stasis disease
 Nephritic syndrome
 Pulmonary embolism
 Pseudotumor cerebri
 Thrombophlebitis (38)
Fatty Liver Disease (nonalcoholic steatohepatitis)
Fatty liver disease occurs when fat builds up in the liver cells and causes injury and inflammation in the
liver, which can lead to severe liver damage, cirrhosis or liver failure. Obese people are likely to develop
diabetes; people who have diabetes are more likely to have fatty liver disease (39). Studies have found
that obesity increases the risk for fibrosis and cirrhosis in patients with alcoholic liver disease (40).
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Type 2 Diabetes
Type 2 diabetes is a disorder of carbohydrate metabolism characterized by hyperglycemia and
disordered insulin metabolism, usually resulting from inadequate or ineffective insulin (3). In a study by
Hu, van Dam, and Liu (2001), findings indicate that a higher intake of saturated fat and trans-fat
adversely affect glucose metabolism and insulin resistance (23).
Over 80% of people with diabetes are overweight or obese (44). Obesity can directly cause some degree
of insulin resistance (3). Being overweight puts added pressure on the body’s ability to properly control
blood sugar using insulin and therefore makes it much more likely for an obese individual to develop
diabetes (45).
According to the National Health and Nutrition Examination Survey (NHANES, 1999-
2002), 51% of those with diabetes had a BMI of 30 or more (46). Data from NHANES III showed that the
prevalence of diabetes increased from 2% in those with a BMI between 25 and 29.9 kg/m2 to 13% in
those with a BMI of 35 kg/m2 or higher (40). The number of diabetes cases among American adults
jumped by a third in the 1990’s. This rapid increase is due to the growing prevalence of obesity and
extra weight in the US population (45).
Diabetes by itself is a risk factor for the following medical conditions which can be life threatening:
 Diabetic retinopathy (eye disease)
 Diabetic nephropathy (kidney disease)
 Diabetic foot disease
 Neuropathy
 Heart disease
 Peripheral vascular disease
 Cerebrovascular disease
 Ketoacidosis
 Hyperosmolar syndrome
 Hypoglycemia (13)
Other medical conditions associated with obesity include poor wound healing, gallstones, gout and
increased risk for surgical complications.
17
Non-Medical Risks Associated with Obesity
The quality of life of an obese individual is less than satisfactory. Obese individuals experience limited
mobility and decreased physical endurance, difficulty with personal hygiene, limited selection in clothing
(10), seats that do not accommodate their large size, low self-esteem, negative self-image, hopelessness
(22) and social stigmatization (18). Obese individuals are thought to be lazy people who lack self
control. They face discrimination in all areas of life such as relationships, education, and employment.
Obese individuals face biased attitudes from medical personnel. This may lead to the avoidance of
obtaining medical care as needed. Research has shown that obese patients are more likely to delay or
cancel appointments to avoid negative experiences.
Obese individuals who experience weight
stigmatization have higher rates of depression, anxiety, social isolation, and poorer psychological
adjustments (47).
ECONOMIC COSTS ASSOCIATED WITH OBESITY
Overweight and obesity, and the health problems associated with each, have substantial economic
consequences for the US health care system. The increasing prevalence of overweight and obesity is
associated with both direct and indirect costs. Direct health care costs refer to preventive, diagnostic
and treatment services related to overweight and obesity. Indirect costs refer to the value of wages lost
by people unable to work because of illness or disability, as well as the value of future earning lost by
premature death (6).
In 1995, the total costs attributable to obesity in the US amounted to an estimated $99 billion. In 2000,
the total cost of obesity in the US was estimated to be $117 billion. Most of the cost associated with
obesity is due to type 2 diabetes, coronary heart disease, and hypertension (6). The WHO estimates the
total cost of obesity at 2%-7% of total health care costs worldwide (8). These increases can be felt in
insurance premiums, deductibles and co-payments.
It has been shown that obese adults face 37.4% greater annual medical expenditures than normalweight individuals (8). In 2002, the Medical Expenditure Panel Survey reported that individuals over the
age of 55 who were obese incurred higher mean medical expenses ($7,235) when compared with
normal weight individuals ($5,390) (7).
18
TREATMENT OPTIONS FOR OBESITY
Treatment options for obesity are just as complex as the disease itself. Most interventions focus solely
on individual dietary consumption and physical activity (5), which is not an appropriate strategy for
success. The treatment of obesity requires lifestyle modification which consists of a multidisciplinary
approach to weight loss. Changing one’s lifestyle requires behavior therapy, diet therapy and exercise
therapy in combination with one another. If these therapies prove unsuccessful, pharmacotherapy may
be introduced. After this, surgical intervention may be considered.
What is success? Obese individuals seeking to lose weight generally have unrealistic goals, which can
lead to disappointment, frustration, self-blame and poor self-esteem, all of which can cause someone to
give up, and possibly gain even more weight. The traditional goal of achieving one’s ideal body weight
(IBW) is no longer considered acceptable (17). The goal should be one of health and not cosmetic. It is
more important to reduce the medical risks associated with obesity than to look model thin which is
unattainable and unhealthy. Studies show that as little as a 5-10% loss of initial weight can reduce risk
factors of morbidity and mortality (21,39). Now that’s success!
Behavior Therapy
Behavior therapy provides methods for overcoming barriers to compliance with dietary therapy and/or
increased physical activity (38). It is designed to promote long-term change (8) that will support weightloss goals and maintenance of weight lost. Behavior therapy can provide a structured lifestyle change,
methods to modify diet and physical activity, cognitive techniques for attitude change, and strategies for
increasing social support (17).
Methods to modify eating and activity behaviors may include:
 Self-monitoring eating – involves recording the how, what, when, where and why of
eating to provide an objective tool to help identify eating behaviors that need
improvement. Also, the act of recording food eaten causes people to alter their
intake. Self-monitoring activity, which includes the frequency, intensity, and type of
activity performed, is also useful.
 Stress management – involves using strategies such as meditation and relaxation
techniques to lower stress, which may improve eating behaviors.
19
 Stimulus control – involves avoiding or changing cues that trigger undesirable
behaviors (e.g., keeping “problem” foods out of sight or out of the house) or
instituting new cues to elicit positive behaviors (e.g., putting walking shoes by the
front door as a reminder to go walking).
 Problem solving – involves identifying eating problems or high-risk situations,
planning alternative behaviors, implementing the alternative behaviors, and
evaluating the plan to determine whether or not it reduces problem eating
behaviors.
 Contingency management – involves rewarding changes in eating or activity
behaviors with desirable nonfood dividends.
 Cognitive restructuring – involves reducing negative self-talk, increasing positive
self-talk, setting reasonable goals, and changing inaccurate beliefs.
Thoughts
precede behavior; changing thoughts and attitude can change behavior.
 Social support – involves getting others to participate in or provide emotional and
physical support of weight loss efforts.
Source: adapted from “Nutrition Essentials for Nursing Practice, 5th edition (22)
Behavior therapy requires gradual change toward realistic goals. Too many changes at once are
overwhelming and ultimately lead to failure; unrealistic goals can cause frustration, also leading to
failure. Behavior strategies need to be tailored to the individual.
Behavior therapy will only be
successful if the patient is motivated to change present undermining behaviors.
It is the clinician’s
responsibility to assess a patient’s level of motivation. Any barriers to change must also be assessed.
20
Table 6. Assessment of Motivation and Change
 Reasons and motivation for weight loss
 Previous history of successful and unsuccessful attempts at
weight loss
 Support system
 Attitude toward physical activity
 Capacity to participate in physical activity
 Time available to commit
 Financial consideration
 Barriers to success
Source: adapted from Kaplan & Sadock’s Comprehensive Textbook of Psychiatry,
8th Edition. (17)
Participants of standard group therapy lose an average of 18 pounds in 15-20 weeks. Longer therapy
can lead to weight loss of up to approximately 30 pounds (22). After one year of treatment, patient’s
regain approximately one-third of weight lost. This can be reduced or avoided by keeping in contact
with patients via follow-up visits, phone calls, or e-mails. Patients will also benefit from attending
support groups.
Diet Therapy
Diet therapy should be used to safely achieve weight-loss goals. A reasonable goal is a loss of one to
two pounds per week. A dramatic weight loss in a short period of time is hard to maintain. It may also
result in the loss of lean muscle mass. A deficit of 500 kcals per day is required to lose one pound per
week; a deficit of 1,000 kcals per day is required to lose two pounds per week. This can be done by
reducing intake or by burning the equivalent number of kcals via physical activity. The latter is more
21
difficult to sustain long-term . It would be more beneficial to supplement a reduced calorie diet with
exercise.
Exercise Therapy
Physical activity is a very important part of a weight loss program and should be used along with diet
and behavior therapy. There are numerous benefits in addition to weight loss. Physical activity can:
 Raise HDL levels
 Improve cardiovascular function
 Release endorphins that make you feel good
 Relieve stress
 Help you sleep better at night
 Increase endurance
Since most obese individuals are not used to an active lifestyle, they should start off with light physical
activity and increase intensity over time as tolerated. A healthy and reasonable goal to strive for is at
least 30 minutes of moderate-intensity physical activity on most or all days of the week. A good place to
start is walking for just 10 minutes a day, 2-3 days per week. Behavior modification can be used to
increase physical activity. For example, choosing stairs over an elevator or walking instead of driving.
The important thing is to keep moving!
Pharmacotherapy
Pharmacotherapy should only be considered when an overweight or obese individual has not
successfully been able to lose one pound per week in the first six months of a weight loss program that
includes behavior modification, diet therapy and exercise (22). Prescription weight-loss drugs are
approved only for those with a BMI of 30 and above or a BMI of 27 and above with any of the following
co-morbidities: HTN, dyslipidemia, CHD, type II diabetes, OSA. Not all people benefit from or respond
to drug therapy. Anyone who fails to lose 4.4 pounds from a weight-loss drug in 4 weeks is not likely to
respond with subsequent use (48). Drug treatment should therefore be discontinued (22).
Drug treatment by itself is not effective and should never be used as the only source of weight-loss. It
should be used to help patients comply with their diet and physical activity plans while losing weight.
Weight-loss drugs could potentially induce as much as a 10% reduction in initial body weight (17),
22
mainly within the first six months of treatment. However, weight loss drugs may only work for as long
as they are being used; benefits may be lost upon cessation (38). Therefore, short-term use of antiobesity drugs are not very effective. It is not known how long drug therapy can be used; to date, there
are no studies indicating the safety of long-term use (22).
There are currently only two drugs that have been approved for long-term use by the Food and Drug
Administration (FDA): sibutramine and orlistat. Their safety and efficacy have not been established for
use beyond two years (46). Sibutramine is an appetite suppressant that works by inhibiting the
reuptake of serotonin and norephinephrine. Clinical trials show daily use of 10-15 mg of sibutramine, in
conjunction with diet therapy, will provide a weight loss of 4-10% of initial body weight, with losses
maintained for up to 2 years (17). Reported side effects include increases in pulse rate, blood pressure,
plasma epinephrine, plasma glucose and other more common side effects include headache 24,50), dry
mouth, constipation and insomnia (30). Use of sibutramine is contraindicated in patients with
uncontrolled HTN, narrow angle glaucoma, history of CAD, CHF, arrhythmias, stroke, severe renal
impairment and severe hepatic dysfunction. Sibutramine should also not be used if patients are
currently taking monoamine oxidase inhibitors (MAOI’s), or selective serotonin reuptake inhibitors
(SSRI’s) such as antidepressants or migraine medications, or centrally acting appetite suppressant
medications (17).
Orlistat binds to gastric, pancreatic, and carboxyl ester lipases in the gastrointestinal tract and blocks the
action of these lipases on dietary triglycerides and vitamin esters. The inhibition of fat digestion
decreases micelle formation and the absorption of long-chain fatty acids, cholesterol, and certain fatsoluble vitamins (30). Approximately one-third of dietary fat is malabsorbed and excreted in stool
(30,48).
Studies show that a regimen of 120 mg of orlistat, three times a day, in addition to diet
therapy, promotes a weight-loss of 5-13% of initial body weight, with losses maintained for up to two
years (17). Studies also show that carbohydrate and protein intake is increased, possibly due to an
indirect stimulation of the central hyperphagic signaling mechanism through lipase inhibition. This can
lead to rapid regain of weight lost (49). Orlistat is generally well tolerated but it is not without side
effects. If an individual consumes more than 30% of calories from fat, he or she may experience any of
the following: abdominal pain, fecal urgency, liquid stools, flatulence with discharge, oily spotting, and
incontinence (17,30). Use of orlistat may require supplementation of fat soluble vitamins that are lost
through fecal excretion. Benefits of orlistat include:
higher levels of HDL, drop in total cholesterol
23
levels, can be used in patients with HTN and cardiovascular complications (17), and helps minimize
weight regain after weight loss (23).
Certain drugs used to treat conditions other than obesity have been associated with short-term weight
loss. They have been approved for use by the FDA for the conditions in which they were intended, but
not for use as an anti-obesity drug. These drugs are being used “off-label” to treat obesity, meaning
they are not being used for their intended purpose (48). These drugs include bupropion, topiramate,
zonisamide and metformin.
Table 7. Off-label Drugs Prescribed for the Treatment of Obesity
Generic Name
Intended Use of Treatment
Bupropion
Depression
Topiramate
Seizures
Zonisamide
Seizures
Metformin
Diabetes
Common Side Effect
Dry mouth, insomnia
Numbness of skin, change in
taste
Drowsiness, dry mouth,
dizziness, headache, nausea
Weakness, dizziness,
metallic taste, nausea
Source: adapted from NIH Publication No.07-4191. (48)
Bariatric Surgery
The first bariatric procedure was performed in 1953 at the University of Minnesota. Although this endto-end jejunoileostomy procedure was associated with severe diarrhea, electrolyte imbalances and liver
failure, which mandated the reversal of the procedure, it paved the way for future bariatric procedures.
By the year 1990, approximately 16,000 bariatric surgeries were being performed annually in the US
(50). In 2006, the American Society for Metabolic & Bariatric Surgery (ASMBS) reported that 177,600
people in the US had bariatric surgery; this represents less than 1% of people who actually qualified for
surgery (46). It is estimated that by the year 2010, 218,000 bariatric surgeries will be performed (8),
over a 1300% increase in just twenty years!
Bariatric surgery is indicated for an individual with a BMI greater than or equal to 40 or a BMI greater
than or equal to 35 with co-morbidities such as CVD, HTN and diabetes, and should only be consider if
there have been multiple failed weight-loss attempts through an interdisciplinary weight-loss program.
24
Individuals should be highly motivated and willing to make changes for life. Bariatric surgery is only a
tool to assist in weight-loss, it is not a “magic bullet. “ Without proper nutrition and exercise, weight
loss from surgery will not be permanent.
Candidates for surgery should be carefully screened preoperatively to ensure they are psychologically
and medically stable. This requires an interdisciplinary approach including physicians, psychologists and
dietitians. A complete medical history should be obtained along with a physical exam and laboratory
tests (i.e. complete blood count; pulmonary, cardiac, and liver function tests).
There are several bariatric surgical procedures being performed today, but the most popular
procedures are the gastric bypass roux-en-y, which is the gold standard in the US (51), and the gastric
adjustable lap band. Other bariatric surgical procedures include biliopancreatic diversion with duodenal
switch and sleeve gastrectomy. These can be performed as open surgery or laparoscopically. Most
procedures today are done laparoscopically, unless otherwise contraindicated (contraindications can
include patients who are extremely obese, who have had previous abdominal surgery or complicated
medical problems).
Laparoscopic procedures require smaller incisions which reduces tissue damage
and complications, resulting in a shorter hospital stay postoperatively (52).
Surgical procedures can be categorized as restrictive, malabsorptive or combined.
Restrictive
procedures induce weight loss by combining a small gastric pouch with a narrow outlet, limiting oral
intake and evoking early satiety (14). Malabsorptive procedures induce weight loss via by-passing
segments of the gastrointestinal tract where various nutrients are absorbed (Figure 2). Nutrients that
are not absorbed as a result of malabsorption are excreted during defecation. This can lead to vitamin
and mineral deficiencies, including iron, vitamin B12, folate, calcium, and the fat-soluble vitamins (A, D,
E, K) (53). Protein deficiencies are also of great concern following bariatric surgery.
Restrictive
procedures, although not malabsorptive, can also lead to deficiencies because of limited intake. Food
intolerances that occur postoperatively can decrease intake as well.
25
Sites of Nutrient Absorption in the GI Tract
Duodenum
Jejunum
Ileum
Stomach




Water
Calcium
Thiamin
Calcium
Ethyl alcohol
Iron
Riboflavin
Phosphorus
Copper
Phosphorus
Niacin
Magnesium
Iodide
Magnesium
Pantothenate
Iron
Fluoride
Copper
Biotin
Zinc
Vit D
Molybdenum
Selenium
Folate
Chromium
Vit K
Intrinsic Factor
Thiamin
Vit B6
Manganese
Magnesium
Riboflavin
Vit C
Molybdenum
Niacin
Vit A,D,E,K
Amino acids
Biotin
Di-,tripeptides
Vit C
Folate
Vit B12
Bile salts/acids
Folate
Vit A,D,E,K
Figure 2. Source: Adapted from Clinical Nutrition for Surgical Patients (53)
Roux-en-Y Gastric By-pass (RYGP): malabsorptive and restrictive
RYGBP (Figure 3a) works by restricting food intake and by decreasing the absorption of food. Food
intake is limited by a small pouch (36) that is about the size of an egg (1-2 ounces) (13). In addition,
absorption of food in the digestive tracts is reduced by excluding most of the stomach, duodenum, and
upper intestine from contact with food by routing food directly from the pouch into the small intestine
(52). Patients experience an excess weight loss of approximately 70% (13).
26
Adjustable Gastric Band (AGB): restrictive
AGB (Figure 2b) works primarily by decreasing food intake. Food intake is limited by placing a small
bracelet-like band around the top of the stomach to produce a small pouch that is similar in size to the
RYGB. The outlet size is controlled by a circular balloon inside the band that can be inflated or deflated
with saline solution to meet the needs of the patient (51). Generally, a weight loss of approximately 5560% of excess weight is achieved (13,55).
Biliopancreatic Bypass Diversion(BPD) with a Duodenal Switch(DS): malabsorptive
BPD, (Figure 3c) usually referred to as a “duodenal switch,” is a complex bariatric procedure that
includes removing the lower portion of the stomach and creating a gastric sleeve with the small pouch
that remains. That pouch is connected directly to the small intestine, completely bypassing the
duodenum and upper small intestine from contact with food. BPD produces significant weight loss;
approximately 80% of excess weight) (13,55). However, the mortality rate is higher than with other
bariatric operations and there are more long-term complications because of decreased absorption of
food, vitamins and minerals (52).
Figure 3 (a), (b), (c). Source: Reprinted with permission from the Bariatric Institute of Wisconsin;
http://www.bariatricwi.com/surgery_types.asp
27
Sleeve Gastrectomy (SG): restrictive
SG is usually performed as the first stage of BPD with DS on GBP in patients who may be at high risk for
complications from more extensive types of surgery. These patients’ high risk levels are due to body
weight and/or existing medical conditions. A SG operation restricts food intake and does not lead to
decreased absorption of food.
However, most of the stomach is removed, which may decrease
production of a hormone called ghrelin. A decreased amount of ghrelin may reduce hunger more than
other purely restrictive operations, such as gastric banding (52). (See section Laparoscopic Sleeve
Gastrectomy for a more in-depth look at this procedure.)
Approximately 10% of bariatric patients may have unsatisfactory weight-loss or regain most of the
weight lost. Inadequate weight loss can be caused by a stretched pouch (from dilatation or dietary noncompliance) or separated stitches (52). Complications that may occur from bariatric surgery include
(13,52):
EARLY STAGE COMPLICATIONS
 Bleeding
 Infection
 Vomiting
 Dumping syndrome (malabsorptive procedures)
 Anastomosis leaks
 Blood clots in legs (which can travel to heart of lungs)
LATE STAGE COMPLICATION
 Malnutrition
 Strictures
 Hernias
o
Incisional
o
Internal
The overall mortality rate from bariatric surgical procedures is approximately 0.5% (37). The leading
cause of death postoperatively is pulmonary embolism (52). But surgery can be well worth the risk. It
can resolve or greatly improve type II diabetes in the majority of patients almost instantly (9). Many
other co-morbidities associated with obesity may be resolved or improved including CVD, OSA, GERD,
28
asthma, gout, hypercholesterolemia, and hypertension (Figure 4).
Bariatric surgery significantly
improves the quality of one’s life.
Figure 4. Source: http://www.asbs.org/Newsite07/patients/benefits.htm
29
LAPAROSCOPIC SLEEVE GASTRECTOMY
Approximately 2% of the bariatric surgeries performed in the US are the laparoscopic sleeve
gastrectomy (LSG) (56), which is quickly gaining popularity among bariatric surgeons as a safe procedure
for weight-loss. This restrictive procedure got its start in 1988 as a modification to the biliopancreatic
diversion (BPD) with duodenal switch (DS) (57).
About 8 years ago, some surgeons who were
performing the BPD with DS operation began to do the SG as a first-stage for super obese and poor-risk
patients, intending to do the second-stage later. They discovered that some patients lost enough weight
with the SG that they did not need to undergo the DS (56).
Surgeons began using SG as the sole
bariatric operation.
Mechanism of Action
LSG is a purely restrictive procedure in which 60-85% of the stomach, including the fundus, is removed,
creating a stomach that measures 1-5 ounces. The fundus is the main production site of the hormone
ghrelin, which stimulates appetite (15). A reduction of ghrelin should theoretically decrease food intake.
Although this has not been proven, many surgeons believe this is one of the reasons for the success of
LSG. The fundus is also the portion of the stomach that stretches the most. Removal of the fundus
leaves a long, vertical, tube shaped stomach that is least likely to expand over time (59). Some surgeons
believe that distention of the gastric antrum due to food accumulation in this area after excision of the
fundus, may be the dominant mechanism of action by decreasing hunger and increasing post prandial
sensations of satiety, thereby reducing food intake (57). Increased satiety may also be related to the
increased pressure within the lumen of the sleeved stomach with its pylorus intact (15). Since the
pylorus remains intact after surgery, the stomach functions normally, without malabsorption.
Indications/Contraindications
As previously noted, SG was initially used as a first-step in BPD with DS. It can also be used as the first
step to RYGBP. It is generally indicated as a first-step procedure for patients with a BMI greater than 50
(super obese). When an individual’s size is of this magnitude, risk of surgery is much greater. LSG is a
less complicated procedure than RYGBP and BPD with DS. The goal is for the patient to lose some
weight before undergoing a riskier bariatric operation. Research recommends a wait time of 6 months
to 18 months, given adequate weight loss, before performing the second-stage surgery.
The super
30
obese may also require a second-stage procedure because weight loss from LSG in this population may
not be significant enough.
As with any bariatric surgery, according to the 1991 NIH Consensus Statement, surgery is indicated for
anyone with a BMI >= 40 or a BMI >= 35 with one or more co-morbid conditions (16). The criteria for
LSG is widening (57); it is now being offered to patients with a low BMI and low risk as an alternative to
laparoscopic gastric banding. LSG may also be indicated for the following individuals (59,11,15):
 Those who are concerned about the potential long term side effects of an intestinal
bypass such as intestinal obstruction, ulcers, anemia, osteoporosis, protein
deficiency and vitamin deficiency
 Those who are considering laparoscopic gastric banding but are concerned about a
foreign body or worried about frequent adjustments or finding a band adjustment
physician
 Those who have experienced a failed gastric banding
 Those with severe medical illness such as cirrhosis, Chrohn’s disease, and anemia
(contraindications for GBP)
 Those needing long-term anticoagulation
 Those requiring the use of anti-inflammatory medications (in GBP, these
medications are associated with a very high incidence of ulcer)
 Those requiring endoscopic surveillance for chronic gastric diseases
 Those with volume eating disorders
 Those with a low BMI needing restrictive surgery
LSG is contraindicated in morbidly obese individuals who have sweet-eating disorders (13). Remember,
LSG is a restrictive procedure only; there is no malabsorption and no dumping syndrome involved. LSG
for a person with a sweet-eating disorder would be counter-intuitive. Technically, an individual post LSG
could eat small amounts of sweets throughout the day with no adverse side effects, other than weight
gain. This person would benefit most from a malabsorptive surgical procedure.
Preoperative Testing/Evaluation
There are several tests and evaluations a patient will undergo prior to surgery at the request of the
primary care physician, surgeon, insurance company and/or hospital where the surgery is to be
31
performed (13). The purpose is to assess the current health of an individual to ensure that he or she
has no medical problems that would increase the risk of surgery. However, if there are medical
problems related to obesity, it increases the need for surgery (60). But by knowing what medical
conditions exist ahead of time, the surgeon can plan a course of action and be prepared.
Testing prior to surgery may include any of the following:
 Physical exam
 Blood work
o
Complete blood count (CBC) – determines if anemia is present
o
Metabolic panel – determines how well kidney and liver work and how well body
absorbs nutrients
o
Liver function tests – determines specific aspects of liver (bile draining, tissues)
o
Prothrombin time (PT) partial thromboplastin time – measures how well blood clots
o
Hemoglobin A1C – determines if diabetic patient has well-controlled blood sugars
o
Free T4, thyroid stimulating hormone (TSH) – determines function of thyroid
 Urinalysis – determines pregnancy status or if presence of infections, complications of diabetes
or nicotine exists
 Cardiac Tests
o
Electrocardiogram (EKG) – determines if heart is working properly
o
Echocardiogram – an ultrasound of heart; determines how well heart is working
o
Stress test – determines ability of heart to stand up to stress
 Pulmonary Tests
o
Chest x-ray – shows the health of lungs
o
Chest CAT scan – a more detailed picture of lungs (if chest x-ray is abnormal)
o
Spirometry – measures the function of lungs and airways
o
Oximetry – measures percentage of blood that contains oxygen
32
o
Arterial blood gas (ABG) – determines ability of lungs to get oxygen into blood and
remove waste produced
o
Sleep studies – determines if sleep apnea is present
 Gall Bladder Tests
o
Ultrasound of right upper abdomen – determines if gallstones are present
 Upper Gastrointestinal Series – used to look at esophagus, stomach and duodenum to
determine if there is any inflammation ,growths, hernias or ulcers
 Vaginal ultrasound – determines abnormalities of ovaries and uterus in women
 Psychiatric evaluation – determines patient understanding of risks and complications of surgery
and ability to comply with postsurgical guidelines
 Nutritional evaluation – determines patient’s past weight-loss attempts and harmful eating
behaviors as well as the ability to change behaviors postoperatively (13,59)
Patients should be strongly encouraged to attend bariatric support group meetings prior to surgery.
This will give them an opportunity to hear first-hand what to expect and to realize that there is a light at
the end of the tunnel.
Surgical Procedure
It is important to have an understanding of the anatomy of the stomach to understand the surgical
procedure. The diagram below illustrates the areas of the stomach (Figure 5).
Figure 5. Source: http://www.nature.com/nrc/journal/v2/n1/images/nrc703-f2.gif
33
There are multiple technical variations to LSG (56) including the number of trocars used, bougie size,
division of the antral area (which can vary from 2 cm – 10 cm proximal to the pylorus) (11,15,56,61) and
whether or not to construct the sleeve first or mobilize the greater curvature first.
A trocar is “a hollow cylinder with a sharply pointed end, often three-sided, that is used to introduce
cannulas and other similar implements into blood vessels or body cavities (62) (Figure 6).” Trocars may
also be bladeless. In laparoscopic surgery, trocars are access ports that are inserted into the abdominal
cavity to allow entry of the required laparoscopic instruments. The first trocar inserted, or primary
trocar, is used to place a cannula through which a laparoscope is inserted to view internal structures
(63). Other trocars are used for laparoscopic hand instruments such as a liver retractor or stapler (62).
Research indicates the use of five or six trocars as common practice (11,56) but use of seven trocars is
also noted in the research literature (Figure 7). Use of fewer trocars may decrease cost, pain and the
number of scars associated with LSG (15).
Trocar/cannulae system:
Figure 6 Source: http://www.righthealth.com/Health/trocars/-od-definition_wiki_Trocar-s (62)
34
Figure 7. Source: http://www.coastalobesity.com/images/Incisions-for-lapar.jpg
A bougie is “a thin cylinder of rubber, plastic, metal or another material that a physician inserts into or
through a body passageway, such as the esophagus, to diagnose or treat a condition. A bougie may be
used to widen a passageway, guide another instrument into a passageway, or dislodge an object (64).”
In LSG, a soft, plastic bougie is used as a guide to create the new, smaller gastric pouch. It is inserted
down the esophagus and into the stomach and pushed against the wall of the lesser curvature of the
stomach. A stapler is then used to cut away the remainder of the stomach to the left of the bougie. The
bougie size is an indicator of the gastric volume that will be created. For example, a 40-Fr bougie
creates approximately an 8 oz pouch. A bougie greater than 40-Fr can cause stretching of the new
stomach (this leaves part of the fundus in tact, which is the stretchable portion of the stomach).
However, bougie size may not always indicate gastric volume. For example, if a smaller sized bougie is
used but moves away from the lesser curvature and toward the greater curvature before stapling (and
this is not corrected), the new pouch will be larger than predicted because of the extra space provided.
35
Likewise, a surgeon may leave too much space to the right of the bougie while stapling, creating a larger
stomach. Bougie sizes for LSG range from 32-Fr to 60-Fr. The 60-Fr is indicated when LSG is used as a
first step in a two-stage procedure such as RYGBP (56).
The First International Consensus Summit for Sleeve Gastrectomy, New York City, October 25-27, 2007
published the surgical procedure of LSG in Obesity Surgery, 2008 as performed by Dr. Gagner (56):
Five or six trocars are used, with the surgeon standing between the patient’s legs. Gagner uses
an open technique for the first trocar, establishing a pneumoperitoneum of 15 mm Hg. Then,
two right trocars, a left trocar, and a midline trocar are inserted, for vision to the upper right.
The right subcostal trocar is used to insert the fan retractor for the liver. The camera is placed
between the umbilicus and xiphoid and has to be high in position. An orogastric tube may be
passed to initially decompress the stomach, and it is then removed. Some surgeons commence
with an opening through the gastrocolic ligament to lesser sac, and initially cut-staple the
vertical channel. Gagner first mobilizes the greater curvature outside the epipoic arcade, close
to the gastric wall, which will be removed. With light traction between two atraumatic forceps,
and starting below the midpoint of the greater curvature, using LigaSure, SonoSurg, Harmonic
Scalpel or coagulating hook, and the patient in slight reverse Trendelenber, the posterior
stomach is visualized. Fine adhesions to the pancreas are divided and the lesser sac totally freed.
Fat must be cleared off the left side of the GE junction, so that later stapling would not be
compromised. Exposure must be high, defining the complete left crus.
Most surgeons commence the dissection 5-10 cm proximal to the pylorus, but some European
surgeons start the resection closer to the pylorus. If the dissection commences too close to the
pylorus, the antral pumping mechanism will be defective, the antrum will not empty properly,
and the patient may have some nausea. The linear stapling division is generally from a right
trocar towards the left shoulder, with or without buttressing material, and leaves about 1 cm of
fat pad along the lesser curvature (~3 cm width). This assures adequate blood supply on the
lesser curvature for the sleeve.
Dr. Gagner starts transecting the stomach 6 cm proximal to the pylorus and then the
anesthesiologist inserts a 36-40-Fr bougie down to pylorus, if the SG is intended as the sole
operation. The sleeve is started at the lower end of the crow’s foot. The procedure requires five
36
to six firings of the linear cutting stapler (60 cm long, 4.8-mm staple-height, green cartridge) to
divide the entire stomach. It is important to remove all fundus to avoid regain of weight. The
vagus nerves anteriorly and posteriorly are preserved for normal gastric emptying.
The greater curvature portion may be extracted in a bag via a right paramedian or epigastric
trocar-site enlarged to two-fingers diameter. The specimen has the shape of a comma with the
fundus at the top. The staple-line is variously oversewn, and many workers do intraoperative
testing via an 18-Fr Argyle tube with diluted methylene blue or air under saline using a
gastroscope, with the prepyloric area compressed. With the bougie removed, Gagner reinforces
each crossing-overlapping site from the stapler with an absorbable monofilament figure-of-eight
suture (56).
Most surgeons will insert a drainage tube into the abdominal area called a Jackson Pratt (JP) drain. This
tube comes out of the body, attaches to a plastic bottle, and drains fluid from inside the stomach. If
there is any infection in the abdominal area, the drain removes the fluid, keeping the patient healthy.
The JP drain may be removed before the patient leaves the hospital, or the patient may go home with it
(13); the surgeon determines the length of time the JP drain remains in the abdomen.
37
Vertical Sleeve Gastrectomy
Figure 8. Source: Reprinted with permission from the Bariatric Institute of Wisconsin:
Bariatricwi.com/surgery_types.asp
1.
The gastrocolic omentum is dissected off of the stomach, freeing up the stomach
2. The sleeve is being created by stapling/removing a large portion of the stomach, beginning in
the antral area, proximal to the pylorus, and firing up preceding in the angle of His.
3. The new stomach pouch is created.
38
Some surgeons may require a patient to wear leg compressors during surgery to prevent the risk of
blood clots. These may also be worn postoperatively while in the hospital.
An upper GI contrast study is performed by many surgeons the day after surgery (56). However, some
surgeons may not perform this test until postoperative day 2. The upper GI contrast study is used to
determine if there are any leaks in the new stomach pouch. A blue dye is ingested by the patient, which
can be tracked and viewed by x-ray as it works its way down from the esophagus into the stomach, to
see if any liquid leaks out of the abdomen. Once it is determined that there are no leaks, the patient
may begin a clear liquid diet as tolerated. Advancement of the diet is based on the bariatric program
guidelines and the patient’s tolerance to the diet. The surgeon or dietitian will let you know when you
may advance to the next stage. Generally, the diet is advanced to full liquids within a day or two,
pureed foods for the next few weeks, soft foods the next few weeks thereafter, until the patient is
healed and ready for a regular diet. It could be several months before a patient advances to a regular
diet. There is no set rule for advancement of the diet, each individual is different in what he/she can
tolerate. For example, some individuals cannot tolerate meat for the first six months whereas others
may be able to eat meat after the first month. (see the Medical Nutrition Therapy for Gastric Sleeve
section for a more in-depth look at the postoperative diet).
Some surgeons may prescribe proton pump inhibitors (PPI) to prevent any acid reflux (15).
A
medication, such as Actigall, may also be prescribed prophylactically to reduce the risk of gallstones.
Research has shown that rapid weight loss can cause the development of gallstones. Most surgeons
recommend that patients take a multivitamin, calcium and possibly a B12 vitamin after surgery (65).
Cost of Surgery
Laparoscopic sleeve gastrectomy generally costs between $20,000 and $25,000 in the US. However, this
procedure is approximately 50-60% cheaper abroad. Medicaltourism.com lists the following prices
outside of the US:
 Mexico - $11,990
 Costa Rica - $8,400
 India - $7,500Puerta
 Vallarta - $11,000
39
Postoperative Complications
There are several complications that may occur if extreme caution and precision are not undertaken by
the surgeon during surgery. The risk of bleeding exists the moment dissection of the gastrosplenic
ligament begins. If dissection of the stomach begins too close to the pylorus, the staple line can crack
and predispose the stomach to leaks.
Leaks have a reported incidence of 0-1.4% up to 5.3% (66).
Dissection too close the pylorus can also lead to improper emptying of the antral area, which may cause
some patients to experience nausea.
Early vomiting may occur if a firm bougie is not used. Dr. Greg Jossart reports a 30% incidence of early
vomiting among his patients (56). Vomiting may also occur as a result of overeating. It takes time for
patients to adjust to their new pouch.
Creation of a long, narrow sleeve can cause stenosis; especially if there is tightness in the construction at
the angularis (56). A gastric fistula can develop but is preventable with the use of an absorbable
buttressing material.
Another complication of LSG (and bariatric surgeries in general) is rhabdomyolosis. Rhabdomyolysis is a
clinical and biochemical syndrome caused by destruction of skeletal muscles which can occur in patients
with a BMI greater than 40 due to an abnormal pressure that disrupts internal cellular structures. It is a
crushing injury from a prolonged stable position. Muscle enzymes should be checked postoperatively
(67).
There can be a delay in the emptying of the proximal gastric pouch if the excision line is swollen. If this
occurs, it needs to be treated with intravenous hyperalimentation for two weeks (54).
Intravenous
hyperalimentation is a form of nutrition that is delivered into a vein. It is prescribed when an individual
cannot use his or her digestive system. In the case of a swollen gastric pouch, it gives the stomach time
to heal instead of aggravating the condition with oral intake.
40
Table 8. Risks and Complications of Laparoscopic Sleeve
Gastrectomy

Esophageal reflux / gastroesopageal reflux

Stapling of gastric tube

Bleeding liver

Failure to position nasogastric tube properly

Failure of staple line (leaks/bleeding)

Gastric fistula

Hemorrhage of spleen

Ventral hernia

Rhabdomyolysis

Defective antral pumping mechanism

Stenosis of gastric sleeve

Gastric fistula

Temporary hair loss

Dehydration

Gastric dilatation

Insufficient weight loss or weight regain – may require
another surgery

Nausea/vomiting

Delay of gastric emptying due to edema of excision line

Deep vein thrombosis

Dehydration

Pulmonary embolism
(11,13,56,57,61,67)
41
Postoperative Testing/Evaluation
Careful follow-up is essential to the patient’s health and success. For the first year, patients should be
seen by a member of a multidisciplinary team including surgeons, dietitians, psychologists, and primary
care physicians at least every three months (68). A CBC should be completed within a few months of
surgery to check for nutritional deficiencies. Weight should be monitored at each visit. If weight loss is
too rapid, the patient may develop gallstones. Rapid weight loss may also cause dehydration. The
clinician should be aware of the signs for dehydration and also monitor the patient for signs of
depression, nausea, and vomiting. Patients may experience depression as they mourn the loss of food.
They may also have trouble dealing with their new found “thinness.” Nausea and vomiting can be an
indication of a more serious complication that may need to be treated.
Follow-up should continue once a year after the first year to continue to monitor progress and any
complications or nutritional deficiencies that may develop. Patients should strongly be encouraged to
continue attending bariatric support group meetings.
Keeping in touch with patients will help them
adhere to the program and maintain a sense of responsibility.
Results
There are no long-term studies greater than 3 years that show sustained weight loss. However, shortterm results are encouraging. The American Society for Bariatric Surgery reviewed the outcomes of 775
patients from 15 published reports and found that patients with a preoperative BMI of 35 to 69kg/m2
had an excess weight loss ranging from 33-83% (67) (Appendix B). (Recall that an excess weight loss of
just 5-10% improves overall health.) The review also showed resolution or improvement in type 2
diabetes, hypertension, hyperlipidemia, sleep apnea, degenerative joint disease, gastroesophageal
reflux disease, peripheral edema and depression (Appendix C).
So, how does LSG compare to the other bariatric surgical procedures?
comparison chart of the various bariatric surgical procedures)
(see Appendix D for a
Research indicates a comparable
percentage of excess weight loss from LSG to RYGBP at 2 and 3 years postoperatively (56). The lack of
intestinal bypass, which is present in RYGBP, avoids potentially costly long-term complications such as
marginal ulcers, vitamin deficiencies and intestinal obstructions (70).
42
Compared to the laparoscopic gastric banding (LAGB), the restrictive effect of food intake with LSG is
similar and does not require a foreign object in the body. There are no adjustments that need to be
made, unlike the band. One surgeon reported that his reoperation rate at 5 years, after 2,000 gastric
banding operations, was 50%. In addition, weight loss and hunger sensation were better after LSG than
LAGB. There was also significantly less vomiting with LSG than LAGB (56).
Table 9. Advantages and disadvantages of laparoscopic sleeve gastrectomy
ADVANTAGES
 Technically an easier procedure in
complex/high risk patients
 Avoids anastomotic complications
 No increased risk of ulcers, strictures,
intestinal complications, internal hernias
 Do not have to alter medications
previously taken
 Ability to “re-sleeve” or perform a second
procedure if weight loss is inadequate
 Less risk of vomiting
 No re-routing of intestines, avoids:
 Marginal ulcers
 Intestinal obstructions
 Anemia
 Osteoporosis
 Vitamin deficiencies
 Deep vein thrombosis and pulmonary
embolism may be less likely to occur
because it is a quicker procedure
 Function of the stomach remains intact
(should eliminate potential for dumping
syndrome)
 Level of ghrelin is much lower
 Can be used instead of GBP if multiple
intraabdominal adhesions are present
 Can be used in patients weighing over 500
pounds
 Very effective as first-stage procedure for
BMI > 55 kg/m2
DISADVANTAGES
 Lack of published evidence for sustained
weight loss beyond 3 years
 Soft calories, such as ice cream and milk
shakes, are easily absorbed and may slow
weight loss
 Irreversible procedure
 Difficulty in finding good, qualified
surgeons
 Usually not covered by insurance
companies
 Sleeve may be stretched out
 weight loss may not be sustained due to:
 Stomach dilatation
 Non-dietary compliance
 Eating disorders
 Alcohol intoxication occurs faster than
with other surgeries
 may produce GERD due to the surgical
division of ligaments around the
abdominal esophagus and destruction of
the cardioesophageal junction
 May not produce anticipated weight loss
results since there is no intestinal bypass
 may cause weight regain because there is
no intestinal bypass
43
MEDICAL NUTRITION THERAPY for SLEEVE GASTRECTOMY
As noted in the medical section of sleeve gastrectomy, the function of the stomach remains intact and
since there is no bypass of the small intestines, there is no incidence of malabsorption. As a result,
nutritional deficiencies postoperatively are rarely seen (55). However, this restrictive procedure does
decrease dietary intake and has a tendency to cause intolerance towards nutrient-rich foods (53), mainly
red meat, poultry and leafy green vegetables, thereby reducing macronutrients and micronutrients
(14). Nutrition care for patients is controversial and recommendations vary widely (33). Most surgeons
do agree on a daily multivitamin (65). Some surgeons will also recommend a calcium supplement and/or
vitamin B-12 supplement (14,65).
Nutritional Deficiencies
Morbidly obese individuals are generally malnourished in the sense that they do not consume a wellbalanced diet and may be deficient in certain vitamins and minerals preoperatively (14). This should be
addressed during the initial screening either by a physician who can have blood serum levels tested to
determine deficiencies or by a dietitian who can review a food frequency questionnaire or 24-hour recall
to evaluate deficiencies. A multivitamin should be prescribed preoperatively if deficiencies are present.
Deficiencies of micronutrients including vitamins A, K, C and E, zinc, arginine, glutamine, copper,
essential fatty acids, bromelain, and bioflavanoids may interfere with wound healing after surgery (14).
Greg Dakin of Cornell, NY, found 85% of his patients to be deficient in vitamin D preoperatively. He
recommends the use of calcium supplements post-operatively for replacement (56).
Postoperative complications, such as excessive vomiting, although a rare occurrence in patients who
undergo sleeve gastrectomy, can lead to:
dehydration, protein-calorie malnutrition, and thiamine
deficiency. This can result in neurologic sequelae (14). Greg Dakin had only one reported incidence of
Wernicke’s syndrome due to thiamine deficiency from vomiting. In the experience of Dr. Jossart, 30% of
his patients experienced early vomiting (56). Thiamine deficiency can be treated with a daily vitamin B
complex with thiamine tablet in addition to the prescribed daily multivitamin.
Protein-calorie
malnutrition can be treated with high protein foods and/or protein supplements (i.e. protein shake). If
dehydration is severe, it may require intravenous fluids to restore intravascular volume (54). Vomiting
may be a sign of dysfunctional eating habits including overeating, eating too fast, or not chewing food
44
well. It is important that the root cause of vomiting be found and addressed immediately to prevent
further nutritional deficiencies. Other causes of vomiting may include:
 Overdistention of the pouch by fluid
 Large volume meals
 Food intolerance
 GERD
 Symptomatic gallstones
 medications
Vitamin B-12 deficiency may occur due to the smaller gastric pouch created by the sleeve gastrectomy.
A smaller gastric pouch reduces acid and pepsin digestion of protein-bound cobalamines in food,
incomplete release of R binders, and decreased production of intrinsic factor (14). B-12 deficiency may
also be caused by inadequate intake of foods rich in B-12. A daily oral or sublingual vitamin B-12
supplement is used to correct this deficiency (a monthly intramuscular injection may be used as well).
Iron deficiency may be the result of a reduced intake of red meat and poultry due to postoperative food
intolerances. Menstruating females may be more susceptible to iron deficiency (33). A daily iron
supplement should be taken along with vitamin C for increased absorption.
Folate deficiency is also possible due to a reduced intake of green leafy vegetables; another
postoperative food intolerance. A multivitamin is generally all that is needed to prevent this deficiency.
Calcium and vitamin D deficiencies are also possible due to reduced dietary intake. Since the stomach’s
holding capacity is much smaller and an individual reaches satiety quickly, foods containing calcium and
vitamin D may not be consumed in sufficient quantities to avoid deficiencies. The American Dietetic
Association (ADA) recommends 1200-1500 mg of calcium citrate daily, which should be taken in doses of
500 mg each to maximize absorption.
To avoid interference with absorption, calcium supplements
should not be taken within two hours of any iron containing supplements (33).
Protein deficiency may occur as a result of inadequate ingestion of protein (33). This can be due to food
intolerance, smaller stomach capacity, vomiting or dietary non-compliance. Supplemental protein (I.e.
protein isolate powder in milk or other liquid) and consumption of protein-rich foods can help prevent
this deficiency. Exercise can help reduce the occurrence of protein deficiency by building lean muscle
45
tissue. Excessive weight loss too soon can deplete protein stores by using lean muscle tissue for energy.
To avoid protein deficiency, the ADA recommends a goal of 1.5 g of protein/kg of ideal body weight
(33). Most physicians recommend a daily protein intake that falls within a range of 60-80 grams.
Mild dehydration is common in the early postoperative period. Patients have difficulty drinking the
necessary amount of fluid as they adapt to very small gastric capacities (54). There are no mathematical
equations that accurately estimate fluid needs in the obese.
Individuals should be encouraged to a
carry around a water bottle (or other non-caloric, clear, non-carbonated fluid source) and sip
throughout the day (54). Bariatric programs differ on the amount of water that should be consumed
daily, ranging from 32 oz to 64 oz. The ADA recommends at least 6 cups of fluid per day, with 3 cups
from high-protein liquid supplements and 3 cups from sugar-free, noncarbonated soft drinks (33). There
are several guidelines that should be followed for the safety and efficacy of patients (Table 10).
46
Table 10. Dietary Don’ts of Sleeve Gastrectomy
DO NOT……
Because…..
Drink liquids with meals
Liquids will fill the small stomach before adequate nutrition
can be consumed; liquids can also move food along the GI
tract more quickly, reducing a longer period of satiety and
leading the individual to eat again sooner than expected.
Drink liquids 30 minutes before or after meals
Liquids will fill the small stomach and produce satiety before
adequate nutrition can be consumed.
Drink beyond fullness
Drinking beyond satiety can cause nausea, vomiting and can
stretch the pouch. Stretching the pouch can lead to increased
intake.
Straws increase swallowed air which can cause the pouch to
Use straws
distend and create an uncomfortable feeling.
Drink caffeinated beverages
Caffeine can contribute to dehydration.
Drink alcoholic beverages
Alcohol has no nutritive value and can contribute to
dehydration.
Drink sweetened, high-caloric beverages
Beverages high in calories can leave little room for needed
nutrients such as protein and can impede weight loss efforts.
Highly sweetened beverages may also cause nausea and
possibly vomiting or diarrhea
Source: Adapted from the ADA’s NCM (33)
47
Nutritional deficiencies can occur from non-compliance of prescribed nutritional supplements and/or
recommended dietary intake. The degree of nutritional deficiency following sleeve gastrectomy is
dependent upon:
 Preoperative nutritional status
 Occurrence of complications
 Ability to modify eating behavior
 Compliance with regular follow-up
 Compliance with prescribed vitamin and mineral supplementation (38)
Preoperative Diet
Not all bariatric programs require a preoperative diet. However, there are some programs that require
an individual to lose weight prior to surgery. The Center for Advanced Weight Loss at St. Francis
Hospital in Trenton, New Jersey, requires patients to lose a minimum of 10-15 pounds prior to surgery
or the surgery will not be performed. Weight-loss decreases the risk of surgical complications. St.
Francis, as well as other bariatric programs, requires a liquid protein diet two weeks prior to surgery to
improve fatty liver conditions, commonly found in morbidly obese individuals. It also helps to improve
protein stores, which is important for healing postoperatively.
The ADA recommends that individuals sample different protein supplements prior to surgery so they are
aware of what is palatable and what is not. It may be difficult for individuals to move around the first
few weeks after surgery. It would benefit the patient to stock his/her pantry with the necessary food
items before surgery (33).
Dietary behavior modification should also begin prior to surgery. Lifestyle changes take time and cannot
be learned over night. In order to be successful, each change should be added one at a time and
subsequent changes should not be added until the prior change has a become a new habit.
48
Postoperative Diet
As you can imagine, the postoperative diet also varies among programs. Generally, the types of diet are
as follows:
 Clear liquid
 Full liquid
 Pureed
 Soft foods
 Regular foods
These diet types are categorized into postoperative stages. The stage and duration is determined by the
surgeon. Each stage is designed to give the patient what he/she needs nutritionally, as well as to help
him/her lose weight safely and effectively. It also gives the patient a chance to heal internally while
getting familiar with a new, smaller stomach (13).
All diets begin with a clear liquid diet day one, provided there are no leaks or other complications
detected after surgery. A barium swallow is usually performed the day after surgery to determine if
there are any leaks. Advancement of diet to the next stage depends on the guidelines of the program as
well as the individual. If a patient does not tolerate advancement to the next stage, he/she will regress
back to the prior stage until the surgeon clears him/her to advance again.
To gain an understanding of the stages and advancement of diet, this paper will provide guidelines taken
from the ADA’s Nutrition Care Manual for bariatric surgery (33).
(Note: it is not specific to sleeve
gastrectomy but is specific to laparoscopic bariatric restrictive type surgery and assumes a four day
hospital stay.)
Day 1:

30 cc per hour sugar-free, noncarbonated, clear liquids

Crystal light or sugar-free Kool-Aid type products

Low-fat, clear broths

Water

Patient should sip, no straws (place a 30 cc medicine cup by bedside)
49
Day 2:


60 cc per hour low-fat, low-sugar, high-protein liquids
o
Skim milk
o
Strained soup made with skim milk
o
Sugar-free yogurt and pudding
o
Bariatric liquid protein supplement
no ice cream or sherbet
Day 3:


semi-liquid, high-protein foods
o
Skim milk
o
Strained soup made with skim milk
o
Sugar-free yogurt and pudding
o
Low-fat strained meats thinned with broth
o
Mashed potatoes with protein powder
1 Tbsp every 15 minutes (2 to 3 oz per hour)
Day 4:

Discharge nutrition (first 2 weeks)
o
Pt should have 3 small feedings (1/2 cup per meal) plus high-protein liquids
o
Pt should have

High protein, low -sugar, low-fat bariatric liquid protein supplement

Liquid or chewable multivitamin and mineral supplements

Liquid or chewable calcium supplement

Regular follow-up with the dietitian after discharge
Weeks 1 & 2:

Limit volume to ¼ cup (4 tbsp) at each meal

Total of 5 cups fluids per day including:
o
3 cups high-protein, low-fat, low-sugar Bariatric Liquid Protein Supplement

Sip 1 oz (30 cc) every 15 minutes between meals
50
o
2 cups other liquids

Water

Sugar-free noncarbonated drinks:

Crystal light

Sugar-free Kool-Aid

Low-calorie cranberry juice

Sugar-free popsicles

Broth
o
½ cup yogurt or sugar-free pudding throughout the day
o
Vitamin and mineral supplements daily
o
No alcohol
o
No chewing gum (if swallowed, may block stomach pouch outlet)
Weeks 3 & 4:


Progress to a Pureed Bariatric Surgery Nutrition Therapy.
o
All foods must be blended to the consistency of applesauce
o
Wait at least 30 minutes after a meal to start fluids
Eat pureed protein foods first. Protein sources include:
o
fish
o
Tender, low-fat meats and poultry
o
Cottage cheese
o
Eggs or egg whites cooked without added fat
o
Tofu
o
Avoid high fat meats:
o

Sausage

Bacon

Luncheon meats

Regular cheese
Meats should be:

Baked

Broiled
51


Braised
Stop eating or drinking when full. Overfilling stretches the stomach pouch and hinders
weight-loss. Being overfull may lead to nausea and vomiting, which can pull out staples
or sutures.

Drink 6 cups fluids daily. This should include the following:
o
3 cups high-protein, low-fat, low-sugar bariatric liquid protein supplement

o
Sip 1 oz every 15 minutes between meals
3 cups other liquids:

Water

Sugar-free noncarbonated drinks:

Crystal light

Sugar-free Kool-Aid

Low-calorie cranberry juice

Sugar-free popsicles

Broth
o
No alcohol.
o
Sip sugar-free, noncarbonated fluids. No straws.
o
No chewing gum.
o
Continue bariatric liquid protein supplement.
o
Continue to avoid fat and sugar.
o
Continue supplements.
4 weeks post-surgery

Progress to Bariatric Soft Nutrition Therapy
o
This nutrition therapy has small feedings that will be followed forever.
o
Wait at least 30 minutes after a meal to start fluids.
o
Continue to eat protein foods first:

fish

Tender, low-fat meats and poultry

Cottage cheese

Eggs or egg whites cooked without added fat
52

Tofu

Avoid high fat meats:

o

Sausage

Bacon

Luncheon meats

Regular cheese
Meats should be:

Baked

Broiled

Braised
After protein foods eat:


Vegetables

Eat only cooked vegetables

avoid those with
o
excessive fiber (celery)
o
tough hulls
o
skins (peas, corn)
then soft fruit canned in its own juice or bananas.
o
No salads or other raw vegetables.
o
Last, eat starchy foods including:
o

Breads

Cereals

Grains

Pasta
Avoid soft bread, doughnuts, and pastries (they may form a dough ball and
become lodged in stomal outlet)

o
It is better to take small bites of toast or crackers.
Stop eating or drinking when full. Overfilling stretches the stomach pouch and
hinders weight loss.
o
Continue bariatric liquid protein supplement.
o
Continue to sip fluids frequently.
53

Aim for 6 cups or more of sugar-free, noncarbonated fluids

Do not use a straw.
o
Continue vitamin and mineral supplements.
o
Continue to avoid sugar and sweets. These foods have many calories.
o
No chewing gum.
o
No alcohol.
After 6 months:

The physician may allow the patient to reintroduce other items as tolerated.
In general, patients will consume 400-800 calories per day in the first few months. Because the pouch is
swollen and sore from surgery, it is difficult to eat and appetite tends to be poor. Usually within four to
twelve months, appetite improves and intake will approximate 1,000 to 1,200 calories per day. It is
important to try and keep a calorie level no greater than 1200 per day until goal weight is attained.
After this time, calories can be increased gradually until weight is stable. This calorie level will be
different for everyone, depending on factors such as height and activity level (13). In order to maintain
weight loss, individuals must continue to follow a nutritious diet that is low in fat and rich in lean protein
sources, whole grains, fruits and vegetables. Remember, weight loss surgery is only a tool to weightloss; proper nutrition, exercise and behavior modification are key.
Nutrition Assessment
The nutritional assessment of a bariatric patient begins before surgery. Most bariatric programs (and
insurance companies) require patients to consult a dietitian at least once preoperatively. Insurance
companies want to see documentation of prior weight-loss attempts. It is also important for the
dietitian to assess the ability of an individual to make necessary diet/behavior changes postoperatively.
Surgery is only a tool for weight loss and should not be performed on individuals who are not willing to
make lifestyle changes.
54
The ADA recommends using the Bariatric Assessment and Presurgical Education Report form to collect
the data needed for assessment and to provide a guide for nutrition education (Appendix E). It is a
comprehensive form that provides the following information (33):
 Client history
 Medical history related to obesity
 Pertinent medications/nutrition supplements
 Diet history
 24 hr recall/food frequency questionnaire (FFQ)
 Disordered eating
 Environmental issues affecting weight
 Activity level
 Support system
 Anthropometrics and weight history
 Patient’s estimated needs
 Nutrition education
 Assessment of understanding of expected dietary/behavior changes
 Postoperative follow-up plans
 Dietitian assessment/evaluation of patient’s ability to undergo surgery
The ADA provides a Nutrition and Eating Habits Questionnaire (NEHQ) (Appendix F), containing a 24
hour food recall and FFQ, which can be sent to the patient to be completed and sent back prior to the
initial dietary consultation. This will give the dietitian a good understanding of the current nutritional
status of the individual, provided that the information given is accurate.
An important part of the nutrition assessment is to educate the patient about the nutrition guidelines
that he or she will have to follow after surgery. As written in the ADA’s NCM, patients need to verbalize
understanding of the following points:
 They will need to be on a liquid nutrition therapy while in the hospital.
 When they go home, they will not be able to eat anything that is not blended or
pureed for approximately 1 month while the area that has been stapled heals.
55
 Their new stomach pouch will be about the size of a chicken egg and they will be
able to eat only about a ½ cup of food at a meal.
 After surgery, they will need to drink about 3 cups of high-protein liquid
supplement. Because of the small size of the pouch, they will need to sip the
supplement in portion of about 2 oz per hour (1 Tbsp every 15 minutes at first).
 They should not drink during the meal or for 30 minutes afterward.
 Sweets and high-fat foods are going to be off-limits. [These high calorie foods can
lead to weight gain and leave little room for needed nutrients.]
 After eating or drinking a small amount (1/2 cup), they will feel that the small pouch
is filled. They must not keep eating or drinking. To do so will stretch the pouch.
Over time, their stomach will hold more and more. Unfortunately, people who do
this do not get the maximum weight-loss from the procedure. In addition, some
who ignore the full feeling and stretch the pouch regain weight they lost.
 No alcohol. It is dehydrating and has no nutrients.
 It is not wise to consume carbonated drinks. The bubbles may cause the pouch to
stretch. It can also cause uncomfortable bloating. Straws are also discouraged
because the person using a straw tends to swallow air, which leads to bloating.
 After a month, patients will be able to eat a soft meal plan. This means tender
meats, cooked vegetables, and fruits canned in water or juice. No salads, raw
vegetables, soft bread, meat with tough fibers or gristle that might block the outlet
of the stomach pouch. Small bites of toast or crackers are acceptable.
 They will have to take nutritional supplements for the remainder of their life.
o
Liquid protein drink – because it is difficult to get enough protein, many
people need to continue to supplement long term.
o
Multiple vitamin and mineral liquid or 2 chewable tablets per day.
o
Calcium – most people need this mineral to promote strong bones.
o
Vitamin B-12 – may be needed if deficiency is present.
o
Iron – given to menstruating women or if the patient becomes anemic.
56
Calculations for Nutrition Assessment
Use the information obtained in the Bariatric Assessment and Pre-surgical Education Report to calculate:
 BMI
 IBW
 % IBW
 Resting Energy Expenditure (REE)
BMI – to calculate BMI, you will need the patient’s height and weight (you should physically measure
and weigh the patient). You may use the BMI table in the appendix to obtain the BMI (Appendix F).
Find the patient’s height in inches and weight in pounds on the chart and find the BMI value on top that
corresponds with these parameters. Note: the patient’s body weight may fall in between two BMI
values. For a more accurate measure, calculate BMI mathematically (33,38):
weight (kilograms)
BMI =
height2 (meters)
If pounds and inches are used:
weight (pounds) x 703
BMI =
height2 (inches2)
IBW – to figure out a patient’s ideal body weight, you need to obtain his/her height and use one of the
following formulas based on the patient’s gender:
Men: IBW = 106 lbs for first 5 feet + 6 lbs for each inch over 5 feet
Women: IBW = 100 lbs for first 5 feet + 5 lbs for each inch over 5 feet
For the individual under 5 feet, subtract 2 pounds for each inch under 5 feet
57
% IBW – to figure out a patient’s % ideal body weight, you need the patient’s ideal body weight and
current weight. Use the following mathematical equation to obtain % IBW:
Current weight (pounds)
% IBW =
IBW
REE – use the Mifflin-St. Jeor (1990) equation to estimate REE (kcal/day) (33). You will need the
patient’s weight in kg, height in centimeters (cm) and age in years. To convert height in inches to height
in cm, multiply inches by 2.54. To calculate, use one of the following based on gender:
Men: (10 x wt in kg) + (6.25 x ht in cm) – (5 x age in years) + 5
Women: (10 x wt in kg) + (6.25 x ht in cm) – (5 x age in years) – 161
Multiply the REE (kcal/day) by an activity factor of 1.3 for sedentary individuals. If needed, use a higher
activity factor to correct for active individuals engaging in exercise or purposeful activity (33).
After assessing the patient, determine the diagnosis, etiology and supporting documentation to create a
PES statement that accurately reflects the current nutrition problem. Always look at the intake domain
first. This statement may change with each subsequent nutrition consultation.
Nutrition Intervention
The ADA’s NCM categorizes nutrition intervention for bariatric surgery into preoperative, hospitalization
and postoperative intervention as follows:
Preoperative Intervention
 Give the patient a copy of the pureed bariatric surgery nutrition therapy at the
initial assessment. Before the surgery, the patient may want to stock up on items
allowed on the discharge eating plan.
 Encourage patients to test various high-protein liquid supplements to find one they
like.
58
 Encourage patients to purchase and try other items they will need. These include
pureed meats, canned tuna, cream of wheat, and cream soups.
 Discuss the importance of vitamin and mineral supplements after the surgery.
 Discuss the importance that physical activity will play in both losing the maximum
amount of excess weight and maintaining weight loss. Lead the patient to start
making plans for physical activity after surgery.
 Provide the patient with recipes for protein supplement use.
 At the second preoperative visit with the patient discuss potential failure of the
surgery. Some reasons patients have failed to maximize weight loss include the
following:
o
Did not make lifestyle behavior changes
o
Drank liquids with meals (stretched stomach pouch)
o
Did not stop eating when felt full (stretched stomach pouch)
o
Emotional issues associated with eating (afraid to be thin)
 Give the patient a list of behavior strategies for avoiding overeating. Ask the patient
to write his or her own list of things that may be helpful.
 It is important for the patient to know that he or she will need help for a couple of
weeks after surgery.
The patient should get up and move around as soon as
possible.
 Reinforce the recommendations about volume of foods and fluids.
Intervention During Hospitalization:
 Postoperative Bariatric Surgery Nutrition Therapy
 Monitor for nausea and vomiting.
 Nursing is responsible for dispensing the 1 oz fluid/hour on postoperative day 1 and
2 oz fluid/hour on postoperative day 2; reinforce the importance of sipping the fluid
between meals so as not to become dehydrated.
 Reinforce no fluids with meals or for 30 minutes after meals.
 Reinforce the discharge eating plan and be sure the patient has copies of education
materials.
59
Postoperative Interventions:
 Bariatric Surgery Nutrition Follow-Up Form
 Advance eating plan to pureed bariatric surgery nutrition therapy
 Regularly assess weight loss
 Always ask the patient to bring in a 3-day food record
 While the patient is in the office, conduct a 24-hour recall.
 Assess nutritional adequacy of patient’s intake for protein and fluids.
 Ask the patient if he or she is continuing to take supplements regularly. Reinforce
the importance of the vitamin and mineral supplements, hydration, plenty of
protein, stop eating when full, and making lifestyle changes.
 Assess current physical activity.
Reinforce the importance of regular physical
activity. It will aid in maximum loss of excess weight and will help with maintenance
of lower weight.
 Use the assessment tool to formulate nutrition diagnoses.
Using the PES
statements, work with the patient to plan and implement specific interventions as
needed.
 Concentrate on behavior changes.
After 4 weeks, the stapled areas should be healed and the patient may progress to the bariatric soft
nutrition therapy.
(Note: this is from the ADA’s NCM. Advancement of diets will vary among bariatric programs. You may
need to adjust information given to a patient based on this.)
Nutrition Monitoring and Evaluation
The ADA recommends using the Gastric Surgery Nutrition Follow-Up form to use as a guide for questions
to ask at every follow-up visit.
60
The NCM divides nutrition monitoring and evaluation into 4 parts:
1. Nutrition Assessment
o
o
24-hour food intake recall
Intake of water or other non-caloric beverages (what kind, how much)
o
Consumption of liquid protein supplement (what kind, how much)
o
Estimated total protein intake/day
o
Assess adequacy of supplement use (ask when and how much)
o
Query the patient about the following:

Drinking while eating (remind to wait 30 minutes after meals to start
liquids)

Carbonated drinks (remind that the gas bubbles will stretch the pouch
and may cause discomfort)

Straws (remind that straws cause swallowing of excess air that can
stretch pouch)
o
o

Chewing gum (swallowing gum can plug up stomach pouch outlet)

Monitor any nausea or vomiting

Hair loss (may be sign of protein deficiency)

Ethanol use
Weight

Current weight

Weight at last visit

Pre-surgical weight

Total weight loss to date

Percent of excess weight that patient has lost
Identify any needed education

Reinforce as needed based on interview questions and responses

Advance nutrition therapy if indicated
2. Write nutrition diagnoses using PES statements
3. Plan nutrition intervention - lead patient in setting goals and strategies
4. Schedule follow-up appointment
61
PATIENT PRESENTATION
KS was thin for most of her life. Her weight troubles began when she quit smoking fourteen years ago
and was then diagnosed with hypothyroidism. Two years later, she married and became pregnant. Four
months after giving birth to her first child, KS was pregnant again. Despite numerous attempts at
weight-loss through the years, KS never achieved more than a 30 pound weight-loss. With each weightloss, KS regained more than she lost.
KS states that she is not an overeater but craves wings, salty foods and chocolate. She is not an
emotional eater and does not eat out of boredom. However, KS eats outside the home a total of 3-6
times per week (breakfast = 1-2x , lunch = 1-2x, dinner = 1-2x,). Her physical activity prior to surgery
consisted of tasks at work, such as transporting patients, and keeping up with her children. About a
month before surgery, KS began bike riding twice a week.
I first met KS the day after surgery. She was extremely motivated to lose weight. I asked her why she
had chosen sleeve gastrectomy as her surgical tool to weight-loss. She responded that she “did not
want her intestines moved,” and didn’t want a malabsorptive procedure. She also did not want to
experience “dumping syndrome.” KS spent 2 days in the hospital.
62
Patient Presentation Outline
Pt:
KS
Sex:
Female
Age:
38
Occupation:
radiology technician at Kennedy Health Systems (KHS) since September, 2007
Hours worked:
8 hrs / day, 40 hrs / week
Family hx:
 married for 12 years
 has two children: 10 year old boy, 9 year old girl
 has one older brother
 parents still married; father is an alcoholic
Social Hx:
 occasional alcohol use
 Quit smoking approximately 13 years ago (1 pack per day for 6 years )
Current dx:
morbid obesity
Past medical hx:
 Small hiatal hernia
 Gastroesophageal reflux disease (GERD)
 elevated cholesterol
 back pain
 hypothyroidism
 hx of kidney stones
 bladder incontinence
Past surgical hx:
 laparoscopy in 1995 & 2000
 laser eye surgery – 1999
63
 tubal ligation – 1999
 thermal balloon ablation – 2007
 D&C – 2007
Family medical hx:
 maternal grandmother – obesity, diabetes
 maternal aunts – obese
 Paternal grandfather – heart disease
Supplements:
MVI
Medications:
synthroid, stopped approximately one year ago
Nexium, stopped approximately 1.5 years ago
Diet / Weight Hx:
 Highest weight:
 Lowest weight:
247# / 112.3kg
130# / 59.1kg
Table 11. Patient reported weight hx from 1/04-1/08
DATE
WEIGHT (lbs.)
1/2/04
227.5
/27/04
230.5
11/30/04
237.9
1/3/05
233
2/2/05
228.5
3/11/05
228
7/29/05
227
8/1/05
227
2/9/06
235
12/14/06
226
2/5/07
236.5
1/16/08
236
64
 Wt loss drugs tried over the last 10 years:

phen-phen

phentermine

hoodia

relacore
achieved 30# weight-loss; regained upon cessation
Table 12. Patient reported weight-loss program attempts
Year
1990’s &
Type of Diet
Weight watchers
Duration of Diet
6 mo-1yr
Wt lost
20#
Duration of weight lost
Couple of weeks
2007
Nutrisystem
4 months
8#
n/a
n/a
Gym Membership
n/a
n/a
n/a
n/a
Trim-Spa
n/a
n/a
n/a
n/a
“The Healthy Weight” at Cooper
n/a
n/a
n/a
2007
Hospital
n/a = information not available
Table 13. Anthropometrics
PRE-OP
1 DAY POST-OP
2 WEEKS POST-OP
1 MONTH POST-OP
2/19/08
5/6/08
5/20/08
6/4/08
HEIGHT
5’6”
5’6”
5’6”
5’6”
WEIGHT
242 #
238*
222#
219#
117-143#
117-143#
117-143#
117-143#
%IBW**
170.6
166.4
155.2
153.1
BMI
39.1
38.5
35.9
35.4
WASIT-TO-HIP
RATIO (WHR)
*pt reported
.85
N/A
.85
.827
IBW
**calculated using upper end of IBW (143#)
65
MEDICAL / SURGICAL COURSE
Surgical Consultations


1/30/08 – initial, discussed available surgical tools to weight loss
4/16/08 – follow-up (f/u), wt. taken

5/21/08 – first post-op visit, wt. and measurements taken, resolution of obesity related
conditions discussed (no reflux, no urinary incontinence), current activities evaluated (jumping
rope, using 5# weights)

6/4/08 – f/u, wt. and measurements taken, review of pt’s current health ( denies n/v/d)

Next f/u scheduled for August; labs will be drawn to check for vitamin/mineral deficiencies
Multidisciplinary consultations for preoperative evaluation:

gastroenterology assessment (2/13/08)
o
Physical assessment revealed:

Blood pressure = 124/84

Pulse = 68

Wt = 240#

Oropharynx clear

No adenopathy or palpable tumors

normal active bowel sounds, non-tender, non-distended


pulmonary assessment (2/18/08)
o
pulmonary function tests – normal
o
may have mild sleep apnea but not enough to warrant sleep study


cleared for surgery from GI perspective
cleared for surgery from pulmonary perspective
psychiatric assessment (2/21/08)
o
mental status revealed:

mood was euthymic

oriented to time, place, and person

speech relevant and coherent

no evidence of flight ideas, hallucinations, delusions, or paranoid ideation

general knowledge and judgment intact
66

insight is adequate


cleared for surgery from psych perspective
KS was made aware by psychiatrist that surgery could lead to depression,
warning signs and symptoms were discussed

cardiac assessment (2/27/08)

EKG – normal

Echocardiogram – normal

Cleared for surgery from a cardiac perspective
67
Table 14. Lab Values
TEST NAME
RESULT
RESULT
RESULT
RANGE
UNITS
April 19, 2008
May 5, 2008
May 6, 2008
Glucose
85
132
132
70-105
mg/dL
Sodium
139
134
138
133-145
mmol/l
Potassium
4.0
3.8
3.9
3.3-5.1
mmol/l
Chloride
104
101
105
96-108
mmol/l
CO2
25
25
28
22-32
mmol/l
14.0
11.8
8.9
10.0-20.0
8
9
10
6-20
mg/dL
Creatinine
0.7
0.8
0.8
0.4-1.1
mg/dL
Calcium
9.3
9.3
9.0
8.4-10.0
mg/dL
WBC
7.6
11.8
12.2
4.8-10.8
X10-3
RBC
4.52
4.57
4.1
4.00-5.2
X10-6
HGB
13.7
14.1
12.9
12.0-16.0
g/dL
HCT
39.8
40.5
36.4
34.9-44.9
%
MCV
87.9
88.6
88.7
81.0-99.0
um-3
MCH
30.3
31.0
31.5
27.3-33.1
pg
MCHC
34.5
35.0
35.5
33.0-37.0
g/dL
RDW
13.6
13.1
13.6
11.5-14.5
%
MPV
9.3
8.7
9.2
7.4-10.4
um-3
Platelet Count
287
271
267
130-400
X10-3
Anion Gap
BUN
68
Hospitalization Summary
Table 15. Medication Administration Record
Medication
May 5, 2008
May 6, 2008
Caefazolin 2 gm/D5W 50 mL
IVPB q8
X

D5/RL 1000 mL IV @ 150 mL/hr
q6.75 hrs
X

Famotidine/Pepcid 20 mg IV q12

X
Heparin 5000 unit subcut q8
X

Hydromorphone/Dilauded 2 mg
IV q3prn


Ketorolac/Toradol 30 mg IV q6
X

Metoclopramid/Reglan 10 mg IV
q6
X


May 5, 2008
o
Admitted to hospital


Diet: NPO
o
Prepared for surgery
o
Surgery performed (see appendix H for surgical report)
May 6, 2008
o
Diet: NPO
o
Barium swallow performed

No leaks or complications discovered

Pt felt painfully full after two small sips of barium solution

Dietetic assessment (see section on Nutrition Care of Patient for full evaluation)
69
o

Diet advanced to bariatric clear liquids
May 7, 2008
o
Discharged from hospital
NUTRITION CARE OF PATIENT

2/29/08 – initial pre-op assessment
o
Assessment:

Reason for surgery – health, wt loss, keep up w/children

Current motivation – children are self-sufficient, has the time to devote, good
support system

Client hx

Medical hx related to obesity

Meds/supplements

Diet hx


Watching portion size

# of meals eaten away from home - ~6x/week

Cravings – wings, chocolate salt

Usual food intake
Activity level

Current: physical at work, keeping up with kids and 2 dogs

Plans post-op: walking, purchased abdominal machine and workout
video

Previous attempts at weight loss (Table 12)

Anthropometrics (Table 13)



Weighed patient
Obtained height and usual body weight (UBW)
Calculated:
o BMI
o
IBW
o
% IBW
70
o
Diagnosis: obesity related to food and nutrition-related knowledge deficit and physical
inactivity as evidenced by BMI = 39 (grade II), patient reports eating out approximately
6x/week, low-intensity physical activity
o
Intervention

Nutrition education for sleeve gastrectomy
o
Changes to the stomach/GI tract
o
Capacity of post-op stomach
o
Anticipated weight loss
o
Pre-operative diet recommendations
o
Post-op diet stages/progression (see appendix I for detail of stages used
at KHS for sleeve gastrectomy)

o
Nutritional considerations after surgery
o
Complications of surgery and what to look for/what to do
o
Exercise
o
Lactose intolerance
o
Meal duration
o
Chewing thoroughly
o
Fluid and protein needs
o
Prevention of dumping syndrome
o
Vitamin/mineral supplementation
o
Portions sizes
o
Label reading
o
Dining out
o
Food records
o
Recipes
o
Hair loss
Set goals for dietary/behavior changes post-op

eat at home before going out

Cook breakfast at home

Plan meals ahead of time

Stick with diet plan/don’t get discouraged
71

Encourage follow-up visits postoperatively for diet reinforcement and to
facilitate healthy wt loss
o
o

Monitor

Weight

Diet

Behavioral changes as stated in goals

Activity level

Commitment to lifestyle changes
Evaluation

Patient’s expectations of post-op eating habits are realistic

Anticipate ability to comply with necessary changes; good family support system
3/10/08 –2nd pre-op assessment
o
Assessment:



Current diet

General diet

Attempting to wean caffeine
Nutritional needs

1650 kcals (based on 16 kcals/kg body weight for weight loss)

52-65 g protein (.8-1.0 g/kg IBW)
Activity level (sedentary)


Anthropometrics

o
physical at work, keeping up with kids and 2 dogs
Measurement taken from prior visit to calculate weight, BMI, WHR
Diagnosis: obesity related to food and nutrition-related knowledge deficit and physical
inactivity as evidenced by BMI = 39 (grade II), patient reports eating out approximately
6x/week, low-intensity physical activity
o
Intervention

Nutrition education for sleeve gastrectomy
o
Principles of Good Nutrition/Food Guide Pyramid
o
Portion control
o
Meal plan = 1600 kcals
72
o
Behavior modification tips
o
Label reading
o
Provided “Lifesteps” referral (a 12-week weight management program
at KHS)


Set goals for dietary/behavior changes

Continue to wean caffeine

Decrease meat portions and increase fruit and vegetable consumption

Record meals 3 days prior to next visit

Ride bike 20 minutes, 2 days per week
Encourage follow-up visits postoperatively for diet reinforcement and to
facilitate healthy weight loss
o
o
Monitor

Weight

Diet

Behavioral changes as stated in goals

Activity level

Commitment to lifestyle changes
Evaluation


Patient will continue to comply with dietary/behavior changes
4/2/08 –3rd pre-op assessment
o
Assessment:



Current diet

1600 kcals

Increased fruit and vegetable consumption

1 meal very high fat
Activity level (moderate)

physical at work, keeping up with kids and 2 dogs

attempting to bike 20 minutes, 2x per week
Anthropometrics

Measurement taken from prior visit to calculate weight, BMI, WHR
73
o
Diagnosis: obesity related to food and nutrition-related knowledge deficit and physical
inactivity as evidenced by BMI = 39 (grade II), patient reports eating out approximately
6x/week, low-intensity physical activity
o
Intervention

Nutrition education for sleeve gastrectomy
o
Supermarket tips
o
Recipe modification
o
Tips for dining out

Reviewed progression of post-op diet

Discussed pre-op preparation at home

Set goals for dietary/behavior changes


Continue to wean caffeine

Decrease high fat foods/meals

Increase fruit and vegetable consumption

Continue to ride bike 20 minutes, 2 days per week
Encourage follow-up visits postoperatively for diet reinforcement and to
facilitate healthy wt loss
o
o

Monitor

Weight

Post-op Diet

Behavioral changes as stated in goals

Activity level

Commitment to lifestyle changes
 Post-op complications
Evaluation
 Patient will continue to comply with dietary/behavior changes
5/6/08 – post-op day 1 assessment (in hospital)
o
Assessment:

Current diet

NPO

Reports poor appetite but is very thirsty
74

Nutritional needs

1622 kcals (based on 15 kcals/kg body weight)

52-65 g protein (based on .8-1.0 g/kg IBW)

Denies n/v/d

Activity level

Currently patient is encouraged to move around without strenuous
activity

o
o
No lifting
o
No driving
Anthropometrics (Table 13)

Weight – pt. reported

IBW

%IBW

BMI
Diagnosis: no nutrition problems at this time (first day post-op patient is on clear liquids
with no prior history of nutritional deficiencies, patient is well-nourished).
o
Intervention



Reviewed post-op diet requirements
o
Progression of diet
o
No straws
o
No caffeine
o
Hydration (consuming at least 32 oz of fluids)
o
Protein shakes
Set goals for dietary/behavior changes

Comply with dietary guidelines

Continue exercising (as approved by physician)
Encourage follow-up visits postoperatively for diet reinforcement and to
facilitate healthy wt loss
o
Monitor

Weight

Tolerance to diet/progression of diet
75
o

labs

Activity level

Commitment to lifestyle changes

Post-op complications
Evaluation



Patient is very motivated to lose weight

Plans to adhere to guidelines

Plans to follow-up with dietitian
Expect good compliance
5/20/08 –1st follow-up assessment (2 weeks post-op)
o
Assessment:

Current diet

Puree (Stage II); began one week post-op

No appetite

Feels full after eating food the size of a quarter (approximately 1 oz)

Consuming protein shake daily

Doesn’t tolerate mayonnaise well anymore

Meeting fluid needs

Taking children’s chewable MVI 2x/day

24-hour food recall:
o
Breakfast –

1-1.5 oz cottage cheese with fruit or shake
OR
6 oz Protein shake made with 1 scoop whey protein
(provides 20 g pro) and 1/3 cup skim milk powder
(provides 8 g pro); takes a few hours to finish shake
OR

o
Yogurt
Lunch/Dinner

1-2 oz chicken puree with broth, 1 oz potato or spinach
OR
76

o
Estimated protein intake = 45 g

Denies n/v/d

Loose stools

Back pain – pt attributes this to surgical table

GERD and urinary incontinence resolved


o
1-2 oz tilapia/tuna or egg
Urinates 4-5x/day instead of 4-5x/hour
Activity level (sedentary/moderate)

Started walking yesterday

Bought a jump rope

Bought 2 – 5# dumbbells

Discontinued all pain meds

Anxious to return to work; feels good

Trouble sleeping 1st and 2nd night due to drain tube (drain tube removed 3rd day)

Anthropometrics (Table 13)

Lost 16 pounds since surgery

Weight

IBW

%IBW

BMI
Diagnosis: inadequate protein intake related to s/p gastric sleeve as evidenced by 24
hour food recall revealing approximately 45 g pro/day.
o
Intervention



Reviewed post-op diet requirements
o
Stage II
o
Protein intake/sources of proteins
Set goals for dietary/behavior changes

60 g protein/day

Talk to surgeon regarding calcium supplementation

Begin exercise 30 minutes, 3x/week with surgical clearance
Requested 3-day food record
77
o
o


Encouraged pt to attend bariatric support group meeting

Scheduled next appointment (June 4)
Monitor

Weight

Tolerance to diet/progression of diet

Protein and fluid intake

labs

Activity level

Commitment to lifestyle changes

Post-op complications
Evaluation

Patient still highly motivated

Expect good compliance and continued weight loss
6/4/08 –2nd follow-up assessment (4 weeks post-op)
o
Assessment:

Current diet

Stage II

Consuming protein shake daily

Meeting fluid needs (water/crystal light)

Supplements:

o
2 children’s chewable MVI
o
Actigall
Patient reported going out to eat for breakfast; had 3 bites of scrambled
egg and 1 bite of pancake and had to stop due to satiety

24-hour food recall:
o
Breakfast

6 oz protein shake, ¼ cup banana (consume ½ and then
finishes other ½ 30 minutes later)
OR

o
Cottage cheese
Lunch
78

½ scrambled egg
OR

o
2 oz tuna/tilapia/chicken
Dinner

2 oz tuna/tilapia/chicken with spinach and mashed
potato
o
Snack

o
3 oz sugar-free pudding

Estimated protein intake = 50 g

Patient did not provide 3-day food record

Denies n/v/d

Normal bowels – no more loose stools

Incision sites achy and tingly (pt reports this is due to rain)

Back pain improved – pt had adjustment by chiropractor

Activity level (moderate)

Bike riding approximately 5 days per week for 30-45 minutes

Bought a jump rope

Bought 2 – 5# dumbbells

Returned to work May 25th

Anthropometrics (Table 13)

Lost 19 pounds since surgery

Weight

IBW

%IBW

BMI
Diagnosis: inadequate protein intake related to s/p gastric sleeve as evidenced by 24
hour food recall revealing approximately 50 g pro/day.
o
Intervention

Reviewed post-op diet requirements
o
Stage III and Stage IV
o
Protein intake/sources of proteins
79
o

o
o
Fiber sources
Set goals for dietary/behavior changes

60 g protein/day

Talk to surgeon regarding calcium supplementation

Continue exercise, 30 minutes 3x per week

Continue to increase fluid intake – long-term goal of 64oz/day

Encouraged patient to attend bariatric support group meeting

Scheduled next appointment (August)
Monitor

Weight

Tolerance to diet/progression of diet

Protein, fluid, fiber intake

labs

Activity level

Commitment to lifestyle changes

Post-op complications
Evaluation

Pt still motivated

Expect good compliance and continued weight loss
80
CRITICAL COMMENTS
KS made an informed decision to undergo sleeve gastrectomy. She attended a presentation given by a
bariatric surgeon at Kennedy Health Systems (KHS), discussing the available surgical procedures. She
then discussed her prior weight, medical and personal history with the surgeon at her initial
consultation. She knew she didn’t want a malabsorptive procedure because she had learned about the
side effects and did not want to experience dumping or nutrient deficiencies. However, given that KS
has a “sweet tooth,” roux-en-y gastric bypass would have been more appropriate (sweets can still be
consumed with sleeve gastrectomy with little to no consequences other than weight gain).
KS’s surgeon took all the necessary precautions to ensure that she was physically and mentally able to
withstand surgery by having her consult with a cardiologist, pulmonologist, dietitian, psychiatrist and
gastroenterologist.
KS met with the anesthesiologist a few days prior to surgery. While she was
hospitalized, she was prescribed pain medications, anti-gerd medications and an anticoagulant. The use
of an anticoagulant was a good, precautionary step to help reduce the incidence of blood clots
postoperatively (recall that the number one cause of death among bariatric surgical patients is
pulmonary embolism). KS She was treated with respect and dignity throughout her hospital stay.
KS’s first post-op visit with the surgeon occurred two weeks after surgery.
I think this should have
occurred one week after surgery just to make sure there were no major problems such as dehydration
or hyperemisis.
KS was prescribed two children’s multivitamins and actigall daily. Since rapid weight loss is associated
with gallstones, I think it was an excellent precautionary measure to prescribe actigall. She was not
prescribed a calcium supplement. Some surgeons prescribe this postoperatively, some do not. Given
that initial intake is anywhere from 400-800 calories, I think it would have been wise to prescribe one.
She is scheduled for a follow-up visit with the surgeon in August (3 month post-op visit) where she will
have blood drawn to check for vitamin and mineral deficiencies. Since KS’s serum Calcium was within
normal limits before surgery, perhaps the surgeon felt supplementation was not needed at this time
(and would be re-evaluated when serum calcium levels are checked in August).
81
KS had several pre-op dietary consultations. She was well educated on the dietary and lifestyle changes
that would be necessary postoperatively. Small, achievable goals were set to begin behavior and dietary
modification. However, KS set a weight loss goal of 77 pounds, to achieve a weight of 165 pounds. KS
most likely will not achieve this goal. Current research indicates short-term excess weight loss at
approximately 60-70%; this would equate to a 60-70 pound weight loss. Of course there have been
individuals who have achieved greater excess weight loss, but this is not the norm. KS is potentially
setting herself up for failure by creating an unrealistic weight loss goal.
There was poor communication between the surgeon and dietitian. A program that houses the surgeon
and dietitian under the same roof would be beneficial to the patient. The dietitian thought KS should be
taking a daily calcium supplement postoperatively. The dietitian instructed KS at the first post-op visit to
mention this to the surgeon. At the second post-op visit, KS was still not taking a calcium supplement. I
am unsure as to whether or not this was mentioned to the surgeon by KS. The dietitian again instructed
KS to mention a calcium supplement to the surgeon. I believe it would have been best for the dietitian
to telephone the surgeon and discuss supplementation. Correspondence consisted of faxing nutrition
assessment forms to the surgeon’s office. Dietitians and surgeons should be working closely together
with bariatric patients.
Although the dietitian working with KS has a basic understanding of bariatric surgery and diet
progression, she is not specialized in the field of bariatrics. Patients deserve dietitians who are
specialized and have experience working with this population. The dietitian meeting with patients
should be present at support group meetings to keep continuity of care. Currently at KHS, the dietitian
attending the support group meetings is not the same as the dietitian assessing bariatric patients.
There are only a few things I would have done differently: weigh KS at all pre-op nutrition consultations,
set a more achievable weight loss goal, improve communication with the surgeon, and attend bariatric
support group meetings. I am not sure if the dietitian will request a copy of the lab results in August –
this is something I would request; I would also ask for a lipid panel to see if KS’s cholesterol level has
improved as a result of the surgery. The dietitian assessing KS had an excellent rapport with her. She
was compassionate, understanding and supportive.
82
SUMMARY
Obesity has reached epidemic proportions over the last twenty years. The causes are not completely
understood but contributing factors include the environment, society, genetics, biology, and psychology.
Behavior, dietary, exercise and pharmacotherapies have proven ineffective for maintaining weight loss.
Bariatric surgery is the only proven method; the restrictive procedure, sleeve gastrectomy, shows
promising results for reducing excess weight and co-morbid conditions but long-term studies are needed
to prove its efficacy.
83
MEDICAL BIBLIOGRAPHY
GENERIC NAME
BRAND NAME
DRUG USE
FOOD/DRUG INTERACTION
SIDE EFFECTS
ursidiol
Actigall
to prevent or
dissolve gallstones
take with food
nausea, abdominal
pain, diarrhea
cefazolin
Ancef/Kefzol
antibiotic
take 2 hrs before or after antacid,
magnesium supplement, iron
supplement or MVI with iron
(otherwise absorption of drug
will be decreased)
diarrhea
famotidine
Pepcid
anti-gerd: increases
gastric pH,
decreases acid
secretions
take drug at least one hour after
iron supplement; decreases iron
and vit B12 absorption;
magnesium or
aluminum/magnesium antacids
decrease drug’s absorption
nausea, vomiting,
diarrhea, contsipation
heparin
Heparin sodium
anticoagulant
none noted
bleeding, hemorrhage,
dizziness, headache,
abdominal pain, GI
bleeding, constipation
hydromorphine
Dilaudid
analgesic
insure adequate fluid
intake/hydration
anorexia, decreased
gastric motility, nausea,
vomiting, constipation
ketorolac
*Toradol
anitinflammatory:
used to treat pain
after surgery
none noted
long-term use can
damage kidneys or
cause bleeding
metoclopramide
Reglan
anti-gerd
avoid alcohol - increases effects
of alcohol; may alter insulin
requirements (caution with
diabetes)
nausea, diarrhea,
restlessness,
drowsiness, fatigue,
dizziness
Source: Food Medication Interactions, 13th Edition (70).
*source: http://www.drugs.com/toradol.html
84
APPENDIX A – Appetite Regulatory Peptides
HORMONE/PEPTIDE/MESSENGER
RESEARCH FINDINGS
APPETITE EFFECT
Agouti-related protein (AgRP)
Overexpression of central AgRP results in obesity; intracerebroventricular
administration of AgRP increases feeding with long-lsating effects while
inhibiting the action of alpha-MSH
increase
Alpha-melanocyte stimulating hormone
(alpha-MSH)
Alpha-MSH is an important melanocortin that inhibits food intake via opioid
pathways.
decrease
AMP-activated protein kinase (AMPK)
Pharmacological activation of AMPK in the hypothalamus is shown to increase
food intake. The molecule is a component of a protein kinase cascade that acts
as an intracellular energy sensor maintaining the energy balance within the cell.
increase
Amylin
Amylin (amyloid polypeptide) reduces food intake and the amylin agonist
pramlintide has been shown to reduce body weight in teyp-1 and type-2
diabetics.
decrease
Bombesin
intraperitoneal injections of bombesin are shown to elicit behavioral satiety
under condition in which gastric, intestinal and postabsorptive mechanisms are
minimally activated by ingested food.
decrease
Brain derived neurotrophic factor (BDNF)
BDNF induces severe, dose-dependent appetite suppression and weight loss
through central mechanisms.
decrease
Cholecystokinin (CCK)
CCK is raapdily released from the gastrointestinal tract postprandially and
stimulates pancreatic secretion, gut motility and gall bladder contraction; it also
inhibits food intake via the brainstem in humans and rodents.
decrease
Cocaine- and amphetamine-related
transcript (CART)
CART is an hypothalamic endocrine signaling protein. When injected
intracerebroventricularly into rats, recombinant CART inhibits both normal and
starvation-induced feeding, and completely blocks the feeding response induced
by NPY.
decrease
Corticotrophin-releasing hormone (CRH)
CRH inhibits feeding and increases metabolic rate when injected into the brains
of animals; it has the opposite effect to NPY. CRH ameliorate obesity through
stimulation of sympathetic nerve-mediated mechanisms and inhibition of vagus
nerve-mediated mechanisms.
decrease
Dopamine
The neurotransmitter dopamine modulates motivation and reward circuits.
Availability of dopamine D2 receptors is found to be decreased in the brains of
obese patients, suggesting dopamine deficiency may cause pathological eating
to compensate for decreased activation of these circuits.
increase/decrease
Dynorphin
Dynorphin is shown to produce highly specific increase in food ingestion.
increase
Endocannabinoids (CB-1)
Endocannabinoids are involved in appetite, eating behavior and body weight
regulation: CB-1 cannabinoid receptor stimulate appetite and ingestive
behaviors.
increase
85
Enterostatin
Enterostatin, the pancreatic polypeptide, has been shown to chronically reduce
fat intake and boy weight, suggesting that it may attenuate the appetite for fat.
decrease
Gamma-aminobutyric acid (GABA)
Studies show that GABA stimulation of hypothalamic GABAA receptors increases
food intake and body weight. Decreasing neuronal GABAergic tone is shown to
inhibit feeding.
increase/decrease
Galanin
The brain peptide galanin is shown to preferentially increase carbohydrate/fatrich nutrient intake in animals.
increase
Ghrelin
Grhelin is synthesized in the stomach and expressed in brainstem and
hypothalamic nuclei. Ghrelin causes hyperphagia in rodents; and plasma levels
are shown to be increased during juman starvation and fall after eating,
indicating its orexigneic potential.
increase
Glucagon-like peptide-1 (GLP-1)
GLP-1 is synthesized via the proglucagon gene in the gastrointestinal tract and
brain where the active peptide GLP-1 amide is released into the circulation after
food ingestion. GLP-1 inhibits food intake in healthy individuals, diabetics and
non-diabetic obese men.
decrease
Histadine/Histamine
hypothalamic histadine suppresses food intake through its conversion to
histamine; dietary histamine has also been shown to decrease food intake and
body fat via activation of histamine neurones.
decrease
Huntingtin-associated protein-! (Hap1)
Hap 1 is highly expressed in the hypothalamus and increases activity at GABAA
receptors; mice lacking Hap1 are found to be hypophagic.
increase/decrease
Insulin
Insulin promotes the conversion of glucose to fat and storage of fat in adipose
tissue. Hypothalamic injections of insulin inhibit feeding, stimulate brown
adipose tissue (BAT) thermogenesis, and causes weight loss. Insulin is believed
to affect food intake by reducing NPY expression in the hypothalamus.
decrease
Leptin
Leptin is secreted by adipocytes and is the gene product of the OB gene. Leptin
deficiency and leptin resistance lead to sever obesity in mice, suggesting that it
might be crucial to the normal control of food intake and body weight.
However, only a few cases of congenital leptin deficiency associated with severe
earaly onset obesity have been documented. Paradoxially, most obese patients
present with hyperleptinaemia, but this has been interpreted as evidence of
leptin resistance, suggesting reduced sensitivity to leptin’s physiological effects.
increase
Mammalian target of rapamycin (MTOR)
MTOR, a serine-threonine kinase, regulates cell-cycle progression and growth by
sensing changes in energy status. Research suggests mTOR signaling plays a role
in the brain mechanisms that respond to nutrient availability, regulating energy
balance. Central administration of leucine increases hypothalamic mTOR
signaling and decreases food intake and body weight.
decrease
Melanin-concentrating hormone (MCH)
MCH found in the hypothalamus increases food intake in a dose-dependent
manner and lowers plasma glucocorticoid levels through a mechanism involving
adrenocorticotrophic hormone.
increase
Melanocortin-$ receptor (MC4R)
The key signaling protein melanocortin-4 receptor (MC4R) is found to be
decrease
86
important in modulating obesity: mutations in the MC4R genes are shown to be
a frequent and heterogenous cause of morbid obesity.
Nesfatin-1
Nesfatin, corresponding to NEFA/nucleobindin 2 (NUCB2), a secreted protein, is
expressed in the appetite-control hypothalamic nuclei in rates.
iNtracerebroventricular injections of NUCB2 are shown to reduce feeding.
decrease
Neuromedin B, C, U and S
Neuromedin peptides are known to inhibit feeding. Neuromedin C
microinjected into the amygdale has been shown to decrease feeding.
decrease
Neuropeptide Y (NPY)
NPY is highly concentrated in the hypothalamus and induces feeding through
receptor subtype interaction that binds NPY. Paraventricular injections of NPY
reduce energy expenditure by inhibiting the sympathetic nerves that innervate
and stimulate BAT, casuing hyperphagia.
increase
Neurotensin
Intracerebroventricular administration of neurotensin produces a dose-related
decreased in food intake.
decrease
Noradrenaline (NA)
Pharmacologic manipulations that elevate noradrenaline can increase or
decrease food intake, depending on the site and type of noradrenaline
manipulation.
increase/decrease
Oleoylethanolamide (OEA)
OEA, and endogenous lipid produced primarily in the small intestine, indirectly
mediates the effects of appetite suppression, reduces blood lipid levels, and
enhances peripheral fatty acid catabolism. OEA also regulates body weight by
altered peripheral lipid metabolism, including increased lipolysis in adipocytes
and enhanced fatty acid uptake in enterocytes.
decrease
Orexin A/Orexin B
Central administration of orexins A and B stimulate food intake and upregulation of prepro-orexin mRNA levels on fasting.
increase
Oxyntomodulin (OXM)
OXM is released from the gut postprandially in proportion to energy intake, and
circulation levels of OXM are increased in several conditions associated with
anorexia. Infusion of OXM is shown to significantly reduce ad libitum energy
intake at a buffet meal and causes a significant reduction in scores for hunger.
decrease
Oxytocin (OT)
Intracerebroventricular administration of OT and an OT agonist is shown to
significantly decrease food intake in a dose-related manner.
decrease
Pancreatic polypeptide (PP)
Intravenous infusions of PP restore normal serum PP levels, and a regimen of
morning and afternoon PP infusions is found to significantly reduce food intake
in Prader-Willi subjects who are characteristically hyperphagic and obese.
decrease
Peptide YY (PYY3-36)
PYY, secreted by the L-cells of the gastrointestinal tract, is released
proportionate to calories ingested. Administration of the active form, PYY3-36,
causes marked inhibition of food intake in rodents and man.
decrease
(cont’d on next page)
POMC is the precursor for melancortins (e.g. alpha-MSH) which cleave other
87
Proopiomelanocortin (POMC)
proteins in the appetite regulation pathway. Homozygous mutations in the
POMC gene cause early onset obesity, adrenal insufficiency and red hair
pigmentation in humans, whereas heterozygous mutations cause subtle defects
contributing to inherited obesity.
decrease
Protein tyrosine phosphatase-1B (PTP-1B)
PTP-1B plays a role in the pathogenesis of insulin resistance in obesity and type
2 diabetes mellitus. PTP-1B activity is found to be significantly reduced in obese
and diabetic individuals compared with controls.
increase/decrease
Satietin
Satietin is blood-borne anorectic glycoprotein that is found to have a longlasting satiatory effect.
decrease
Serotonin (5-HT)
The neurotransmitter serotonin is a well-established anorectic and its
hypophagic effect requires activation of 5-HT1A and 5-HT1B receptors.
decrease
Triiodothyronine (T3)
Peripheral and hypothalamic triidothyronine directly stimulates feeding:
peripheral administration of T3 has been found to double food intake in ad
libitum-fed rats over 2h, whereas injection of T3 directly into the hypothalamus
is shown to produce a fourfold increase in food intake in the first hour.
incresae
Uncoupling proteins (UCPs/thermogenin)
Mitochondrial membrane proteins (e.g. UCP-1, 2 and 3) usually found on brown
adipocytes play a role in energy balance and weight gain. Transgenic ablation of
adipocytes that express UCP1 and UCP2 results in obesity in mice suggesting the
UCPs in BAT metabolism are important in energy balance and obesity.
increase
Source: reprinted with permission from T.J. Atkins (50)
88
APPENDIX B
89
APPENDIX C
90
APPENDIX D
91
APPENDIX E
92
APPENDIX e
93
APPENDIX E
94
APPENDIX E
95
APPENDIX E
96
APPENDIX F
97
APPENDIX F
98
APPENDIX F
99
APPENDIX F
100
APPENDIX F
101
APPENDIX F
102
APPENDIX G
103
APPENDIX H– Surgical Report of Patient
FINDINGS: Dense adhesions between the posterior aspect of the stomach and the anterior surface of
the pancreas.
ESTIMATED BLOOD LOSS: 20 mL.
BRIEF HISTORY OF PRESENT ILLNESS AND INDICATION FOR PROCEDURE: The patient is a 38-year-old
female with morbid obesity. Medical complications related to her morbid obesity refractory to
nonoperative weight loss attempts now for definitive surgical procedure. Discussed with the patient at
length the risks, benefits, possible alternatives, possible complications of the procedure including the
possibility of leak, blood clots, intractable bleeding. Consent obtained.
PROCEDURE: The patient was brought to the operating room theater, prepped and draped in the
normal sterile fashion after the success of general anesthesia. Foley and OG tube were placed. Suitable
sites for a skin incision were selected in the right upper quadrant. A 5-mm skin incision was made with
the #15 scalpel blade with dissection through soft tissue with the bladeless trocar. The abdomen was
entered without difficulty. The abdomen was insufflated to 15 mmHg. The abdominal contents were
inspected with no damage to the underlying structures. A 12-mm port was placed in the supraumbilical
position, a 5-mm port was placed in the epigastrium, two 12-mm ports were placed in the left
hemiabdomen, a 5-mm port placed in the left anterior axillary line, a 15-mm port placed in the right
hemiabdomen. The stomach was fully decompressed with the G-tube and the G-tube was removed.
The gastric sac was entered by dividing the omentum along the greater curvature of the stomach with
the ligature device. This was carried up to the angle of His and then down along the greater curvature of
the stomach to a point approximately 6 cm from the pylorus along the antrum. The stomach was then
elevated up. Dense adhesions were encountered between the posterior aspect of the stomach and the
pancreas suggesting a prior inflammatory process. These were taken down with the use of blunt and
sharp dissection with the use of the ligature device. At this point due to the dense posterior adhesions
the decision was made to only proceed with the gastric restricted portion of the procedure. A vertical
gastrectomy was then performed. Starting approximately 6 cm from the pylorus two 60-mm green
cartridges were fired along a 40-French bougie and then the remaining fires were 60-mm blue cartridges
preceding in the angle of His. The gastrectomy specimen was removed through the 15-mm port site.
The anastomosis was tested, submerged under saline solution with intraoperative EGD and there was no
evidence for a leak. The staple line was covered with Tisseel. A #19 Blake drain was positioned through
the 5-mm port site in the left hemiabdomen adjacent to the staple line. The liver retractor in the
epigastrium was then removed. The 12 and 15-mm port sites were closed with 0 Vicryl suture and an
Endoclose device. The abdomen was desufflated. The skin incisions were irrigated and closed with
staples. The patient tolerated the procedure well, was extubated and brought to the recovery room in
stable condition
104
APPENDIX I – Kennedy Health Systems Diet Progression for Sleeve Gastrectomy
STAGE I – CLEAR LIQUIDS
Clear liquids generally begin after an upper GI “swallow test” is performed. Your surgeon will order the
diet, usually the day after surgery, and it will continue for the next few days.
 In the hospital you will get diluted juice (2oz juice & 2oz water), broth, and diet gelatin on each
tray
 Try to sip fluids at the rate of 1-2oz per hour. A “medicine” cup or shot glass may assist in
measuring this portion size
 Goal: consume 32oz (4 cups) fluid per day in order to prevent dehydration
Sipping fluids out of bottles or straws may cause gas, which may lead to indigestion, bloating and
abdominal discomfort, so avoid using them.
Food to Choose
Guide to Clear Liquid Choices
Foods to Avoid
Diluted fruit juice:
Fruit nectars or juices with pulp
 Apple
 Cranberry
 Grape
Water
milk /milkshakes
Crystal light or other sugar-free drink mixes
cream soups
Sugar-free popsicles
sweetened drink mixes
Diet gelatin
cocoa
Broth
*Carbonated beverages
Sugar substitutes
 Soda
 Sparkling water
 seltzers
alcohol



Splenda
Equal
Sweet-n-low
coffee
tea
*carbonation may cause gas, bloating, and stretch the pouch
105
STAGE II – SMOOTH CONSISTENCY
The next step of the diet progresses to puree foods, which are low in fat and contain no sugar. Foods
should be pureed to a smooth consistency without any lumps. During this stage, only a few tablespoons
will be consumed at meals and snacks. This will last approximately 2-3 weeks.
 Foods include: skim milk, pureed poultry and meat, mashed potatoes and unsweetened
applesauce, unsweetened yogurt, sugar-free puddings, cream of rice, cream of wheat
 May utilize protein powder or shakes
 Begin vitamin/mineral supplementation (1 month after surgery)
 Eat every 3-4 hours
 Sip liquids all day long, and wait 30 minutes after a meal
 Prepare food ahead of time and freeze in ice-cube trays, which can later be reheated
 Each meal should initially be ½ cup (8 Tbsp) and progress gradually to ¾ cup
 A healthy, well balanced diet should include food sources from the following groups:
o
Protein: 6-8 servings per day
o
Vegetable: 2 servings per day
o
Bread/Grains (starches): 2 servings per day
o
Fats: 3 servings per day
Stage II Sample Menu

Breakfast: ¼ cup pureed cottage cheese with 1/8 cup pureed peaches

Lunch: 2 ounces (about ¼ cup) pureed tuna fish and 1/3 cup puree vegetable

Snack: ¼ cup sugar-free pudding (suggestion: add protein powder)

Dinner: ¼ cup pureed chicken with ¼ cup smooth mashed potatoes and 1/3 cup pureed
vegetable

Snack: ½ cup skim milk or applesauce with protein powder
106
STAGE III – MINIMAL TEXTURE
After 2-3 weeks following surgery, progress to soft, cooked foods as tolerated.
 Initially a “cottage cheese” consistency, still pureed but not as smooth
 Next, increase to finely ground meats, soft fruits, cooked vegetables as tolerated and
unsweetened cereals
 Finally, advance to diced poultry (without skin)
 Still follow low-fat and low-sugar choices
 Continue to sip fluids all day long

Begin vitamin and mineral supplements (1 month after surgery)
 Each meal should be ¾ cup to 1 cup in size
This stage lasts approximately 2-3 weeks.
Check with your physician.
Stage III Sample Menu

Breakfast: 1 egg poached or scrambled, and ¼-1/2 cup oatmeal with protein powder. Take
multivitamin

Fluids: 1c decaffeinated coffee or sugar-free lemonade, sip slowly; 2oz every 15 minutes

Snack: 1-2 ounces (slices) low-fat cheese (example: Alpine Lace Cheese)

Fluids: 1c skim milk or water, sip slowly; 2oz every 15 minutes

Lunch: 1-2 ounces turkey, 1/8-1/4 cup cooked carrots, and 1/8 cup fruit

Fluids: 1 cup skim milk or water, sip slowly; 2oz every 15 minutes

Snack: 1 cup protein supplement or ½ cup sugar-free instant pudding with protein powder

Dinner: ¼ cup ground beef, ¼ cup mashed potatoes, and ¼ cup cooked broccoli

Snack: ¼ cup cottage cheese and ¼ cup diced peaches (puree if needed)

Fluids: 1 cup diluted juice, sip slowly; 2 oz every 15 minutes; take calcium supplement
107
STAGE IV – SOLIDS & MAINTENANCE
Gradually advance to solids, usually about six to eight weeks after surgery. This step is now considered
the maintenance level which will be followed for the rest of your life! It consists of high protein, low-fat,
low-sugar foods. Slightly larger amounts of food are now able to be tolerated, but remember not
watching portion sizes can lead to weight gain as the pouch will stretch.
 Gradually add whole grains, limit fat and sugar
 Pay attention to volume
 Remember to eat high protein foods first, focus on 3-4 ounces of protein per meal
 Drink constantly just before or after meals
 Strive for a high fiber diet by including non-starchy high fiber carbohydrates such as oatmeal or
cracker type foods
 Gradually add fresh fruit and vegetables
 In general, each meal should be about 1-1/2 cups in size
 Eat slowly, taking 20-30 minutes for a meal
Stage IV Sample Menu





Breakfast
o 1 egg
o 1 slice wheat bread
o 1 tsp butter
Snack
o 2-3 ounces low-fat cottage cheese
o 3 strawberries
Lunch
o 3 ounces of turkey
o 1 slice wheat bread
o 1 tsp light mayonnaise
o 1 slice tomato
Dinner
o 3 ounces of chicken
o ¼ cup broccoli
o ¼ cup potato
Snack
o 1 Tbsp peanut butter (creamy)
o 3 crackers
108
109
110
REFERENCES
1. Center for Disease Control. Obesity among adults in the United States—no statistically
significant change since 2003-2004.Center for Disease Control. Available at:
http://www.cdc.gov/nchs/pressroom/07newsreleases/obesity.htm. Published November 2007.
Accessed May 25, 2008.
2. World Health Organization. Fact sheet No. 311. Obesity and overweight. World Health
Organization. Available at: http://www.who.int/mediacentre/factsheets/fs311/en/print.html.
Published September 2006. Accessed May 25, 2008.
3. Pinna K, Rolfes SR, Whitney E. Understanding Normal and Clinical Nutrition, 7th edition. US:
Thomson Wadsworth: 2006.
4. Burke, LE, Cartwritght MA. Obesity: an overview of assessment and treatment. In: Bridges, EJ,
Froelicher ES, Motzer SA, Woods, S, ed. Cardiac Nursing, 5th Edition. Lippincott Williams &
Wilkins; 2005:42.
5. Catenacci VA, Hill JO, Peters JC, Wyatt HR. International strategies to address obesity. Obesity
Reviews. 2008;9:441-47. Accessed June 1, 2008.
6. US Department of Health and Human Services. The surgeon general’s call to action to prevent
and decrease overweight and obesity 2001. Center for Disease Control. Available at:
http://www.cdc.gov/nccdphp/dnpa/pdf/CalltoAction.pdf. Published 2001. Accessed May 25,
2008.
7. Mattar, SG. Lifting the unbearable weight of morbid obesity. Annals of Surgery. 2008;247:28-29.
doi:10.1097/SLA.Ob013e318160c1fc.
8. Jones DB, Powers KA, Rehrig ST. Financial impact of obesity and bariatrics Surgery. The Medical
Clinics of North America. 2007;91:321-338. doi:10.1016/j.mcna.2007.01.001.
9. Mathier MA, Ramanathan RC. Impact of obesity and Bariatric Surgery on Cardiovascular Disease.
The Medical Clinics of North America. 2007;91:415-431. doi:10.1016/j.mcna.2007.02.002.
10. Buchwald, H. Consensus conference statement bariatric surgery for morbid obesity: health
implications for patients, health professionals, and third-party payers. Surgery for Obesity and
Related Diseases. 2005;1:371-381.
11. Blanc PM, Bomans B, de Seguin de Hons C, Fabre JM, Gagner M, Krawczykowsky D, Millat B,
Monnier L, Nocca D, Picot MC. A prospective multicenter study of 163 sleeve gastrectomies:
results at 1 and 2 years. Obesity Surgery. 2008;18:560-565. doi:10.1007/s11695-007-9288-7.
12. Dietel, M. A synopsis of the development of bariatric operations. Obesity Surgery. 2007;17:707710.
13. Davidson BK, Kurian MS, Thompson B. Weight Loss Surgery for Dummies. Indianapolis, IN: Wiley
Publishing Inc.: 2005.
14. Rosenthal R, Szomstein S, Tucker O. Nutritional consequences of weight-loss surgery. The
Medical Clinics of North America. 2007;19:499-514. doi:10.1016/j.mcna.2007.01.006.
15. Arar N, Beglaibter H, Givon-Madhala O, Lustigman H, Spector R, Stein M. Technical aspects of
laparoscopic sleeve gastrectomy in 25 morbidly obese patients. Obesity Surgery. 2007;17:722727.
111
16. Kohan G, Oria As, P LTC, Quesada BM, Roff HR. Laparoscopic sleeve gastrectomy as an
alternative to gastric bypass in patients with multiple intraabdominal adhesions. Obesity
Surgery. 2008;18:566-568. doi:10.1007/s11695-007-9302-0.
17. Brownell Kd, Phelan S, Wadden TA. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry,
8th Edition. Lippincott Williams & Wilkins; 2005:24.3.
18. Escott-Stump S, Mahan KL. Krause’s Food, Nutrition, & Diet Therapy, 11th edition. Philadelphia,
PA: Saunders: 2004.
19. National Heart, Lung and Blood Institute (NHLB). NIH Publication No. 00-4084. The practical
guide: identification, evaluation, and treatment of overweight and obesity in adults. Available
at: http://www.nhlbi.nih.gov/guidelines/obesity/prctgd_c.pdf. Published October 2000.
Accessed May 25, 2008.
20. National Institute of Diabetes and Digestive Kidney Disease. Statistics related to overweight and
obesity. Weight-control Information Network. Available at:
http://win.niddk.nih.gov/statistics/index.ht. Updated June 2007. Accessed May 25, 2008.
21. National Institute of Health. Publication No. 01-3680. Understanding adult obesity. Weightcontrol Information Network. Available at: http://win.niddk.nih.giv/understanding.htm.
Published October 200l. Updated March 2006. Accessed May 25, 2008.
22. Obesity and Eating Disorders. In: Dudek S, ed. Nutrition Essentials for Nursing Practice, 5th
Edition. Lippincott Williams & Wilkins;2006:14.
23. Escott-Stump S. Nutrition and Diagnosis-Related Care, 5ht edition. Baltmiore, MD: Lippincott
Williams & Wilkins: 2002.
24. Janssen I, Mark AE. Elevated body mass index and mortality risk in the eldery. Obesity Reviews.
2007;8:41-59. doi:10.1111/j.1467-799X.2006.00248.x.
25. Center for Disease Control. Obesity by the Numbers. Obesity in America. Available at:
http://www.obesityinamerica.org/trends.html. Accessed: June 5, 2008.
26. Bellisar A. Evolutionary origins of obesity. Obesity Reviews. 2008;9:165-180. doi:10.1111/j.1467789X.2007.00392.x.
27. Stunkard A, Wadden T. Handbook of Obesity Treatment. New York, NY: Guilford Press: 2002
28. Drent ML, Jakobsdottir S, Klok MD. The role of leptin and ghrelin in the regulation of food intake
and body weight in humans: a review. Obesity Reviews. 2007;8:21-34. doi:10.1111/j.1467789X.2006.00270.x
29. Bray GA Popkin BM, Wolf A. A short history of beverages and how our body treats them. Obesity
Reviews. 2008:9:151-164. doi:10.1111/j.1467-789x.2007.00389.x.
30. Approach to the patient with obesity. In: Alpers D, Kaplowitz N, Laine L, Owyang C, Powell D, ed.
Textbook of Gastroenterology, 4th Edition;2003:36.
31. Astrup A, Dyerberg J, Selleck M, Stender S. Nutrition transition and its relationship to the
development of obesity and related chronic diseases. Obesity Reviews. 2008;9:48-52.
32. RD411. The sleep /weight connection. RD411. Available at:
http://www.rd411.com/article.php?ID=227. Accessed June 5, 2008.
33. Nutrition Care Manual. American Dietetic Association. Available at:
http://www.nutritioncaremanual.org. Accessed June 25, 2008.
112
34. Office of Genetics and Disease Prevention Public Health Perspectives. Obesity and Genetics:
what we know, what we don’t know and what it means. Center for Disease Control. Available
at: http://www.cdc.gove/genomics/training/file/print/perspectives/obeseknow.pdf. Accessed
June 5, 2008.
35. Bouchard C, Loos RJF. FTO: the first gene contributing to common forms of human obesity.
Obesity Reviews. 2008;9:246-250. doi:10.1111/j.1467-789X.2008.00481.x.
36. World Health Organization. Fact Sheet No. 311. Obesity and overweight. World health
Organization. Available at: http://www.who.int/mediacentre/factsheets/fs311/en/index.html.
Published: September, 2006. Accessed May 25, 2008.
37. DeMaria EJ. Greenfield’s Surgery: Scientific Principles and Practice, 4th Edition. Lippincott
Williams & Wilkins; 2006:47.
38. National Heart, Lung and Blood Institute (NHLB). NIH Publication No. 00-4084. The practical
guide: identification, evaluation, and treatment of overweight and obesity in adults. Available
at: http://www.nhlbi.nih.gov/guidelines/obesity/prctgd_c.pdf. Published October 2000.
Accessed May 25, 2008.
39. National Institute of Health. Publication No. 07-4098. Do you know the health risks of being
overweight? Weight-control Information Network. Available at:
http://win.niddk.nih.gov/publications/health_risks.htm. Published November 2004. Updated
October 2007. Accessed May 25, 2008
40. Approach to the patient with obesity. In: Alpers D, Kaplowitz N, Laine L, Owyang C, Powell D, ed.
Textbook of Gastroenterology, 4th Edition;2003:36.
41. The Obesity Society. Obesity Statistics: Obesity Trends. The Obesity Society. Available at:
http://www.obesity.org/stastistics/obesity trends.asp. Accessed June 1, 2008.
42. Davis G, Gagne DJ, Patel JA. Pulmonary consideration in Obesity and the bariatric surgical
patient. The Medical Clinics of North America. 2007;91:433-442.
doi:10.1016/j.mcna.2007.02.001.
43. The Obesity Society, Fact Sheets. Obesity and Cancer. The Obesity Society. Available at:
http://www.obesity.org/information/cancer_obesity.asp. Accessed June 1, 2008.
44. The Surgeon General. Overweight and obesity: health consequences. United States Department
of Health and Human Services. Available at:
http://www.surgeongeneral.gov/topics/obesity/calltoaction/fact_consequences.htm. Updated
January 1, 2007. Accessed May 25, 2008.
45. The Obesity Society, Fact Sheets. Obesity and Diabetes. The Obesity Society. Available at:
http://www.obesity.org/info/diabetes_obesity.asp. Accessed June 1, 2008.
46. American Society for Metabolic & Bariatric Surgery. Metabolic surgery expected to play bigger
role in treating type 2 diabetes and other metabolic disease. American Society for Metabolic &
Bariatric Surgery. Available at:
http://www.asbs.org/Newsite07/resources/press_release_8202007.pdf Published August 22,
2007. Accessed May 25, 2008.
113
47. The Obesity Society. Obesity, bias, and stigmatization. The Obesity Society. Available at:
http://www.obesity.org/information/weight_bias.asp. Accessed June 5, 2008
48. National Institute of Health Publication No.07-4191. Prescription medications for the treatment
of obesity. Weight-control Information Network. Available at:
http://win.niddk.nih.gov/publications/prescription.htm. Published November 2004. Updated
December 2007. Accessed May 25, 2008.
49. Atkins TJ. Central and peripheral neuroendocrine peptides and signaling in appetite regulation:
considerations for obesity pharmacotherapy. Obesity Reviews. 2008;9:108-120.
doi:10.1111/j.1467-789X.2007.00412.x
50. Elgamal MH, McLeod MK, Saber AA. Bariatric surgery: the past, present, and future. Obesity
Surgery. 2008;18:121-128. Doi:10.1007/s11695-007-9308-7.
51. Folli F, Pontiroli AE, Schwesinger WH. Metabolic aspects of bariatric surgery. The Medical Clinics
of North America. 2007;91:393-414. Doi:10.1016/j.mcna.2007.01.005.
52. National Institute of Health. Publication No. 08-4006. Bariatric surgery for severe Obesity.
Weight-control Information Network. Available at: win.niddk.nih.gov/publications/gastric.htm.
Accessed June 5, 2008.
53. Bloomberg RD, Fleishman A, Herron DM, Kini S, Nalle JE. Nutritional deficiencies following
bariatric surgery: what have we learned? Obesity Surgery. 2005;15:145-154.
54. Marian M, Russell M, Shikora SA. Clinical Nutrition for Surgical Patients. Sadbury, Ma: Jones and
Bartlett Publishers; 2008:6.
55. Laparoscopic Associates of San Francisco. Surgery Comparison Chart. Laparoscopic Associates of
San Francisco. Available at: http://www.lapsf.com/weight-loss-surgeries.html.
56. Crosby RD, Deitel M, Gagner M. The first international consensus summit for sleeve gastrectomy
(SG), New York City, October 25-27, 2007. Obesity Surgery. 2008;18:487-496.
Doi:10.1007/s11695-008-9471-5.
57. Askoxylakis J, Daskalakis M, Karkavitsas N, Koukouraki S, Melissas J, Perisinakis K, Stathaki M.
Sleeve gastrectomy – a restrictive procedure? Obesity Surgery. 2007;17:57-62.
58. Frangou C. Respect for sleeve gastrectomy grows among surgeons. Gastroenterology &
Endoscopy News. 2007;58:12.
59. ObesityHelp.com. Vertical sleeve gastrectomy (VSG) – also known as sleeve gastrectomy,
vertical gastrectomy. ObesityHelp.com. Available at:
http://www.obesityhelp.com/forums/vsg/mode,pcontent/cmsID,8874/.
60. ObesityHelp.com. About Obesity. ObesityHelp.com. Available at:
http://www.obesityhelp.com/content/aboutobese.html/mode.pcontent/cmsID,2409/aboutobe
se. Published 2008. Accessed June 6, 2008.
61. Cho M, Kaidar-Person O, Pinto D, Roa PE, Rosenthal RJ, Szomstein S. Laparoscopic sleeve
gastrectomy as treatment for morbid obesity: technique and short-term outcome. Obesity
Surgery. 2006;16:1323-1326.
62. Laparoscopic Associates of San Francisco. Vertical sleeve gastrectomy (vsg) – frequently asked
questions. Obesity Help.com. Available at:
http://www.obesityhelp.com/forums/vsg/mode,pcontent/cmsID,8457/
114
63. Ashar B, Corrado J, Fuller J, Scott W. Laparoscopic trocar injuries: a report from a U.S. Food and
Drug Administration (FDA) Center for Devices and Radiological Health (CDRH) Systematic
Technology Assessment of Medical Products (STAMP) Committee. U.S. Food and Drug
Administration (FDA) Center for Devices and Radiological Health (CDRH) Systematic Technology
Assessment of Medical Products (STAMP) Committee. Published: November 7, 2003. Updated:
June 24, 2005. Available at: http://www.fda.gov/cdrh/medicaldevicesafety/stamp/trocar.html.
Accessed June 13, 2008.
64. Medicine Net. Definition of bougie. Medicine net. Available at:
http://www.medterms.com/script/main/art.asp?articlekey=12497. Accessed June 13, 2008.
65. Kosmix RightHealth. Trocars. RightHealth. Available at:
http://www.righthealth.com/Health/trocars/-od-definition_wiki_Trocar-s. Accessed June 13,
2008.
66. Dapri G, Cadiere GB, Himpens J, Vax C. A prospective randomized study comparing two different
techniques for laparoscopic sleeve gastrectomy. Obesity Surgery. 2007;17:1435-1441.
67. Formato A, Forestieri P, Monda A, Pilone V, Romano A, Tramontano S. Rhabdomyolysis after
sleeve gastrectomy: Increase in muscle enzymes does not predict fatal outcome. Obesity
Surgery. 2008;18:349-351. doi:10.1007/s11695-007-9356-z.
68. Saltxman E, Shikora S, Tarnoff M. Managing obesity – options for obese and morbidly obese
patients. The Journal of Family Practice. Supplement May 2007. Available at:
www.jfponline.com. Accessed May 25, 2008.
69. American Society for Metabolic & Bariatric Surgery. Position statement on sleeve gastrectomy
as a bariatric procedure. American Society for Metabolic & Bariatric Surgery. Available at:
http://www.asbs.org/Newsite07/resources/sleeve_statement.pdf. Published June 2007.
Accessed May 25, 2008.
70. Laparoscopic Associates of San Francisco. About vertical gastrectomy. Laparoscopic Associates
of San Francisco. Available at: http://www.lapsf.com/vertical-gastrectomy-weight-losssurgery.php. Accessed June 1, 2008
71. Pronsky ZM. Food Medication Interactions, 13th Edition. Birchrunville, PA:Food-Medications
Interactions:2004.
115