managing post-bariatric surgery patients in our …...managing post-bariatric surgery patients in...

Managing Post-

Bariatric Surgery

Patients in our

Health UnitsA Nursing Care Perspective

Kimberly K. Ottwell, MD

RMM---American

Embassy Bangkok

CNE 2017 Lisbon1

"I'm not only the Hair Club president,

I'm also a client.“ Sy Sperling's Hair Club for

Men commercial 1986

My Disclaimer:

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The 3 Most Common Bariatric

Surgery Procedures in the USA

Laparoscopic Adjustable Gastric Banding

(LAGB)(Quickly falling out of favor due to complication rate

and lower weight loss/lack of metabolic effects)

Laparoscopic Sleeve Gastrectomy (LSG)(Quickly rising in popularity)

Roux-en-Y Gastric Bypass(RNY)

(The Gold Standard)

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Estimates of Bariatric Surgery in

the USA2011 2012 2013 2014 2015

Total 158,000 173,000 179,000 193,000 196,000

RNY 36.7% 37.5% 34.2% 26.8% 23.1%

LAGB 35.4% 20.2% 14% 9.5% 5.7%

LSG 17.8% 33% 42.1% 51.7% 53.8%

BPD/DS 0.9% 1% 1% 0.4% 0.6%

Revision 6% 6% 6% 11.5% 13.6%

Other 3.2% 2.3% 2.7% 0.1% 3.2%

Balloons ~700

cases

V-bloc 18

cases

Data from ASMBS5

Current thoughts on Pathophysiology:

Metabolic Surgery—It is much more

complicated than just restrictive vs.

malabsorptive The mechanisms of action are not as simple as just

restrictive or malabsorpitive---but instead include multiple physiological variables that affect

endocrine and neuronal signaling.

Glucagon-like peptide-1 and peptide YY after RNY & LSG

Ghrelin production with any procedure that bypasses the

fundus where this is produced

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Current thinking: Metabolic

Procedures vs. Non-Metabolic

Procedures

Metabolic RNY

LSG

Non-Metabolic Procedures LAGB

Balloons

*Patients having Metabolic Procedures have several weight-loss advantages

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Laparoscopic Adjustable

Gastric Banding

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Laparoscopic Adjustable

Gastric Banding

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Laparoscopic Sleeve

Gastrectomy

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Laparoscopic Sleeve

Gastrectomy

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Roux-en-Y Gastric Bypass

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Roux-en-Y Gastric Bypass

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Bariatric Surgery: Tool vs. Cure For

Managing Obesity and the

Comorbidities

Dietary changes

Exercise Changes

Lifestyle Changes—

Holistic behavioral measures

The New Paradigm: Metabolic Surgery15

What is Success with Bariatric

Surgery?

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Weight Loss---

what is

realisticWeight loss of 60%-70% of excess body weight is achieved in the short term, and up to 50% at 10 years. Those who develop and maintain the lifestyle changes for the rest of their lives will maintain the weight loss.

A “Genetic Re-Set” of the Patient’s Weight

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Calculating Excess Weight

Pre-surgical Weight - Goal weight (BMI <25)

EXCESS WEIGHT

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Body Mass Index

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What is typical weight loss in

first 12-18 months after

LSG/RNY?

Variable!!

1-2 pounds/week is average for LSG or RNY

The majority of people plateau by 12-18 months with around 60-70% of Excess Body Weight off

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Median Excess Weight Lost (%)

0 20 40 60 80

Overall

LAGB

LSG

RNY

7-10 years

3-6 years

1-2 years

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Remission of

DM 2Remission of Diabetes mellitus occurs in 60%-80% of patients 1-2 years after RNY, and remission is maintained in approximately 30% at 15 years.

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Reduced

MortalityBariatric surgery reduces all-cause mortality by 30%-50% at seven to 15 years after RNY compared to those not having surgery.

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Link Between Obesity &

Mortality

BMI has been determined to be a strong

predictor of overall mortality.

At a BMI of 30-35, median survival is

reduced by 2-4 years.

At a BMI of 40-45, it is reduced by 8-10

years (comparable with the effects of

smoking!)

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What Makes a Person Successful in

both losing and maintaining

weight loss?

30%

30%

35%

5%

Variables

Diet

Exercise

Lifestyle changes

Supplements

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Diet—Control food portions for calorie reduction

Diet—Eat nutrient dense foods

Exercise—Engage in physical activities you enjoy for exercise

Support—Participate in nutritional counseling

Support—Participate in bariatric exercise programs

Support—Participate in counseling to deal with the emotional and mental aspects of obesity and weight loss surgery

Support—Participate in bariatric support groups and weight loss surgery forums

Set Goals—Monitor success of weight loss

Steps to Weight

Loss Success

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Nursing Aspects that Must Be

Addressed in the Post-

Bariatric PatientWhat Can I do to Help My Patient Be Successful At

Utilizing Their New Tool?

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Key Points To Consider

How to appropriate monitor and track progress

Nutritional and Fluid Advise and Compliance

Exercise Advise and Compliance

Compliance with supplements

Birth Control for women of reproductive age

Emotional Health and Accountability

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Obtaining Accurate Vital Signs

Body Composition Scales--Is a relatively easy to

administer method of measuring body fat percentage. Bioelectrical impedance analysis works by determining the electrical impedance of the body tissues, which provides an estimate of total body water, which can be used to estimate fat free mass and percentage body fat.

Appropriate Blood Pressure Cuff size

Abdominal Circumference

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Body Fat Percentages

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Cuff size and Blood Pressure

Readings

http://www.aafp.org/afp/2005/1001/p1391.html

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Measuring Blood Pressure Blood pressure cuff selection and sizing

Errors in measurement of blood pressure have been shown to be significant when the blood pressure cuff is too large or too small. The error of “miscuffing” is the most common error in an out-patient setting when it comes to blood pressure measurement (Pickering et al. Circ 2005;111:697-716). The majority of these errors occur when clinicians use blood pressure cuffs that are too small for the patients. The ideal cuff size should have a bladder length that is 80% of the armcircumference, a width that is at least 40% of the arm circumference, and a length-to-width ratio of 2:1.

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Measuring Waist

Circumference

http://www.cutthewaist.com/measuring.html

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Waist Circumference cut-off

Values

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Diet and Nutritional Support

Nutrition and Eating/Drinking Habits

Portion control/size

Nutrition of what they eat

“Nutrient-dense Foods”

When they eat/drink

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Portions The typical “mature” pouch can hold 6-12 ounces

of solid food at one time.

Goal of 3 small meals of 6-12 ounce volume with use of snacks when needed.

Initially, those volumes will be as low as 2 ounces!

Eat slow, chew your food, and focus on your meal

You should stop eating after 20 minutes maximum---”no letting it settle to be able to eat more”

No “Grazing”

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Nutrition The patient needs to eat nutritionally dense

food

General concept of 70-90 grams of protein/day

General concept of focusing on eating lean proteins first to make sure the patient gets their protein within their volume limits

1/3 of plate protein, 1/3 fruit or veggie, and 1/3 complex carbohydrate “whole grain” that is eaten last if patient still hungry

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Fluids

Water or other non-carbonated, low/no

calorie options

~64 ounces of fluid/day

Avoid fluids 20-30 minutes before eating

and then for 30-60 minutes after eating

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Exercise-Goal 1 hour daily of

“exothermic exercise” as a

minimum has been linked to

better maintenance of weight-

loss

-Trainers, PT, Exercise

Physiotherapist to help patient

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Psychological Support of the

Bariatric Patient

• Continued screening for depression/anxiety

• Education and screening for relationship

issues

• Body image

• “Buyer’s Remorse”

• Addiction Transference Concerns

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Compliance & Accountability

Weight-loss surgery is not a cure for obesity,

but rather a tool to help patients lose

weight to live a healthier, longer and more

fulfilling life. Success depends on their ability

to follow guidelines for diet, exercise and

lifestyle changes. Consider the first 12-18

months the honeymoon phase to learn

those new skills for a lifetime of success.

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Resources For Your Patients

E-Books that may be of help:The Success Habits of Weight Loss Surgery Patients (3rd

Edition) by Colleen M. Cook

The Big Book on the Gastric Sleeve: Everything You Need

to Know To Lose Weight and Live Well With the Vertical

Sleeve Gastrectomy by Alex Brecher & Natalie Stein

Bariatric Support Groups

Do a quick search on-line for your city

On-Line Resources (see next slide)

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https://my.clevelandclinic.org/ccf/media/Files/BMI/patient-handbook.pdf?la=en46

Nursing Bariatric

Flow SheetCreate a Flow Sheet for

following your bariatric patients

in the Medical Unit.

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Case Study #1The patient is a 42 year-old female who underwent a

laparoscopic sleeve gastrectomy 8 months ago. She presents as a

new patient to your medical unit.

Pre-surgical weight was 238.6 #

Pre-surgical height was 5’7”

What was her pre-surgical BMI? ________

What was her excess body weight? (calculate) ________

On today’s visit the patient weights 218#

What is her BMI on today’s visit? ______

What percentage of ideal body weight has she lost? _______

How is she doing? What else would you want to ask her?

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A little more to the story: Diet: Breakfast—a piece of buttered toast with a fried egg and 2

pieces of processed cheese melted on top. Lunch and dinner pasta with cheese sauce. Unsure of how much fluids she drinks. Drinks diet sodas and juices.

Exercise: Minimal exercise---does not like to get hot and sweaty. Occasional ½ mile walk with dog 1-2 times/week.

Supplements: Not taking any! Swears no one mentioned these to her.

Mental Health/Social concerns: Taking Zoloft for depression---reports “Doing OK---just OK.” Others report she drinks considerable amounts of ETOH---she states occasional use but does not want to quantify. Does not attend support group/no individual counseling.

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What would you do next?

Educate?

Support?

Resources you might turn to?

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Case Study #240 year old female reports that she underwent RNY surgery in 2004 for

obesity and related poorly controlled DM 2. She has had a complete

resolution of her diabetes. Initial pre-surgery weight was 256 pounds

(height 5’3”) putting her initial BMI @ 44-45 range and her excess body

weight at ~125#. She reports she reached her maximal weight loss

with a BMI of 26.6 at about one year post procedure. Today (2014), 10

years post procedure her weight is 171 # with a BMI of 32---she is

frustrated and feels something is wrong!

Review of habits:

Diet: consistent with high protein intake (frequently grazes),

estimates 1200-1300 kcal/day, consumes 2-3 gin & sodas

4/7 nights with friends, occasionally more on weekends

Exercise: Works out with trainer 5/7 days

Supplements: Takes occasional Gummy vitamins

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Is This Patient At An Expected

Weight for 10 years Post-RNY?

Currently her weight loss is at ~68% of her

excess body weight

Could she do better?

What about her nutrition/diet?

What about her exercise?

What about her supplements?

What about her mental health/social

concerns? (How about her ETOH use?)

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References Blackwood, H. (2012). Postoperative care of the bariatric surgery patient.

RN.com. Retrieved from https://lms.rn.com/getpdf.php/1837.pdf

California Medical Association & California Association of Health Plans (2013). Pre/Post Bariatric Surgery Provider Toolkit. Retrieved from http://www.thecmafoundation.org/Portals/0/assets/docs/obesity/Pre-Post-Bariatric-Surgery-Provider-Toolkit.pdf

Cleveland Clinic Bariatric Surgery Patient Handbook (2016) retrieved from https://my.clevelandclinic.org/ccf/media/Files/BMI/patient-handbook.pdf?la=en

Richardson, W, MD, Plaisance, A, PA-C, Periou, L, RD, LDN, Buquoi,J RN, CBN, and Tillery, D, RN, CBN (2009) Long-term management of patients after weight loss surgery. Ochsner J. 2009 Fall; 9(3) 154-159.

Schroeder, R, MD, Harrison, D, DO, and McGraw, S, MD Lehigh Valley Health Network, Allentown, Pennsylvania (2016) Treatment of adult obesity with Bariatric Surgery. Am Fam Physician from http://www.aafp.org/afp/2016/0101/p31.html

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