bariatric surgery work up, patient selection and follow...

The University of Sydney

Bariatric Surgery Work

Up, Patient Selection

and Follow Up

A/Professor Tania Markovic

Metabolism & Obesity Services, RPAH

Boden Institute of Obesity, Nutrition,

Exercise & Eating Disorders


SLHD Bariatric

Surgery

Programme

1. NSW Health Recommended Criteria for Eligibility for Bariatric Surgery, NSW Obesity Management Plan (2009)

2. National Institute for Health and Clinical Excellence (NICE) Guideline 43: Obesity: guidance on the prevention,

identification, assessment and management of overweight and obesity in adults and children (2006)

3. AACE/TOS/ASMBS Guidelines 2009


Eligibility criteria at SLHD

– Aged between 18 - 70

– Pregnancy not anticipated in first two years post surgery

– Initial BMI ≥ 40 with an associated obesity illness which will improve with weight loss

– Body weight does not exceed weight limits of equipment necessary for patient care pre, or immediately post operatively

– Obesity related morbidity


Edmonton Obesity Staging Sysyem (EOSS) –

Cardiometabolic Disease

Stage Description Management

0 No apparent obesity-related risk

factor

Identification of factors contributing to increased

body weight. Lifestyle counseling.

1 Presence of obesity-related

subclinical risk factors

- Borderline HPT, IFG, LFTs

Investigations for other (non weight related)

contributors to risk factors. More intense lifestyle

intervention. Monitoring of risk factors.

2 Presence of established obesity-

related chronic disease

- HPT, T2DM, PCOS, NASH

Initiation of obesity treatments incl

behavioural/pharm/surgery. Management of

comorbidities

3 Established end-organ damage

- Myo infarction, heart failure,

cerebrovasc dis, diabetic

complications, cirrhosis

More intensive treatment incl pharm/surgery.

Aggressive management of comorbidities.

4 Severe (potentially end stage)

disabilities

- Renal failure, PVD/amputation,

hepatic failure/HCC

Aggressive obesity management as deemed

feasible. Palliative measures may be more

appropriate.

Sharma AM & Kushner RF Int J Obes 2009;33:289-295


Sunil D et al, Curr Opin Endocrinol Diabetes Obes 2013; 20(5): 377-88


EOSS predicts outcomes better than BMI

– Analysis of National Health and Nutrition Examination Surveys (NHANES) data

– NHANES III (1988-1994) n = 4367

– NHANES 1999-2004 n = 3600

– EOSS score assigned to those with BMI > 25

Padwal RS et al, CMAJ, 2011


Padwal RS et al, CMAJ, 2011


Eligibility criteria at SLHD

– Absence of other medical conditions that would increase the morbidity or mortality risk of bariatric surgery

– Comprehensively assessed as fit for surgery by specialist physician, endocrinologist, anaesthetist and bariatric surgeon

– Psychological profile– Undergone comprehensive psychosocial evaluation, and free of acute

psychiatric issues, or drug dependency problems

– Proven to be able to comply with and adhere to the behavioural changes required after surgery

– Capacity to understand the associated risks and commitment

– Well-informed and motivated


SLHD Bariatric surgery criteria: Commitment

– Regular attendance at one of the weight management programs in SLHD or SWSLHD for at least 12 months

– Has adhered to lifestyle prescriptions during the period of time attending the weight management programme

– Expectation that patient will adhere to postoperative care including attending follow-up visits with physician(s) and team members and following instructions/advice provided


% weight loss pre surgery vs post surgery – 6 months

p = 0.6


% weight loss pre surgery vs post surgery – 48 months

p = 0.06


SLHD Bariatric surgery criteria

– Irreversible endocrine or other disorders that can cause obesity

– Current drug or alcohol abuse

– Uncontrolled, severe psychiatric illness

– Lack of comprehension of risks, benefits, expected outcomes, alternatives, and lifestyle changes required with bariatric surgery

– Inability to attend post surgical follow up appointments


Important questions

– How did you come to make this decision about having surgery? What are your reasons for undertaking this procedure?

– What is your understanding of what this procedure involves?

– What is your understanding of the risks involved in this procedure?

– How will surgery affect your lifestyle in the future?

– Expectations- Goals for your weight loss post- surgery and anticipated time-frame?

It is important patient understands the surgery

they will have, and that they have realistic

outcome expectations


What to expect post surgery

– Improved health

– 40% or greater excess weight loss

– Annual blood test, BMD review as necessary

– Daily multivitamin lifelong

– Adhere to a reduced kcal intake (approx 1/3 of usual intake)

– Abstain from liquid calories, and abstain from snacking

– Eat slowly, include balanced meals & small portions

– Include daily structured exercise


– 12 months of lifestyle program and fulfilment of inclusion criteria

– Reviewed by endocrinologist at Metabolism & Obesity Services

– Reviewed by Clinical Psychologist Metabolism & Obesity Services

– If therapist, endocrinologist and psychologist agree that surgery is indicated patient is referred to the Sydney Local Health District Bariatric review committee (monthly meeting)

– If surgery approved appointment with surgeon

– Discussion regarding appropriate surgery type

– Additional weight may need to be lost, further investigations may need to be attended

– Surgeon approves surgery

Bariatric surgery referral process


Pre surgery requirements

All patients scheduled for bariatric surgery are to adhere to

a full Very Low Energy Diet (VLED) for a minimum of two

weeks prior to surgery.

THIS IS COMPULSORY AND IS FUNDED BY THE

PATIENT

https://www.google.com.au/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjAjri3ja7XAhVDi5QKHX3IBK0QjRwIBw&url=https://www.optislim.com.au/&psig=AOvVaw3Kb7ufVGK9wSNRVqRnhG4W&ust=1510200503734665


Medications

Post bypass- extended

release medication are

not to be used


Why is follow up important?


All bariatric surgeries are weight loss tools and will not

work long term if diet and exercise prescription are not

followed


Diet transitioning time frames

post bariatric surgery

FluidsPuree

Diet

Soft

Diet

Solid

Diet

Week 1- 2 Week 9 onwardsWeek 3- 4 Week 5- 8

Sleeve

Gastrectomy

Minimum yearly

appointments afterwards


Post surgery diet regimen

Average plate size

Bariatric plate size

Sleeve

Gastrectomy

50% meal vegetables/ salad

50% lean protein &1 tbsn

carbohydrates (not essential)Pictures: “Portion perfection for

bands and sleeves”- Amanda

Clark

1 teaspoon per

minute

Take small mouthfuls

Chew everything

thoroughly

Eat slowly

DO NOT drink with

meals


Avoid soft food when onto solids. More volume can be consumed in

one go compared to solid food

Post surgery diet regimen

Solid diet – from week 8

If you have not finished your meal within 30 minutes either throw the

rest away or put it in the fridge for your next meal.

½ cup protein ½ cup vegetable portions

DO NOT GRAZE BETWEEN MEALSDaily intake

SHOULD NEVER EXCEED

5000 – 6300 Kilojoules / 24hours

(1200- 1500 Calories)

POST SURGERY

Should avoid soft foods & liquid calories


Prioritise Protein and Vegetables


DO NOT CONSUME CARBONATED BEVERAGES

The bubbly nature of carbonated drinks, can cause gas pain and increase the pressure in your stomach


It is the patient’s responsibility to:

• Choose the correct food

• Make healthy choices

• Follow post surgery diet &

exercise prescription

THE SURGERY IS NOT A POLICE

OFFICER. IT WILL NOT STOP YOU

BREAKING THE RULES.

We will support patients, but it is their

choice how they eat post surgery


Post surgical complications

Surgery type Early complications Late Complication

Band/ Sleeve/ Bypass •Wound infection

•Clot in leg or lung

•Dysphagia

•Gastrointestinal bleeding

•Incisional hernia

•Micronutrient deficiency

• Abdominal pain require

investigation

•Reflux, regurgitation or dysphagia

•Inconsistent or inadequate weight

loss

Sleeve/ Bypass •Enteric Leak from surgical wounds

•Functional or mechanical obstruction

of stomach

•Osteoporosis and anaemia

•Anastomotic Stricture (0-6%)

• Food impaction related to altered

gastric motility

Gastric Sleeve •Pouch dilation (results from consistent

over eating)

Gastric bypass •Dumping syndrome •Dumping syndrome

Adjustable Gastric Band •Reoperation rate at 10 years 10-

20%

• Band/ gastric slippage

•Band erosion

•Oesophageal dilatation

•Tubing and port- related problems


Dumping Syndrome

Occurs in 10% of patients post bypass

Two types of dumping:

1. Early dumping (30- 60 minutes after meals)

2. Late dumping (1- 3 hours after eating)

To reduce effects of dumping:

• Try increasing meal frequency and reducing meal

size

• Avoid foods and drinks containing high sugar

levels. Sugar is emptied rapidly from the stomach

causing symptoms


Nutrient deficiencies

Most at risk

– Iron, vitamin B12, folate, calcium, vitamin D, thiamine, fat-soluble vitamins

By pass > SG >LAGB

1. Reduced quantity

2. Reduced quality (intolerances/fads)

3. Maldigestion/reduced bioavailability (acid, pepsin; reduced length of common channel-by pass)

4. Malabsorption (by pass absorption site)

5. Increased losses (vomiting)


Follow up therapy sessions

– It is believed those who do not attend follow up post-surgery do worse than those who continue being reviewed by their bariatric team

3 monthly 6 monthly YearlyOR OR


No difference in weight change between regular and

irregular follow-up groups

Mixed Model 1 Comparison of predicted mean

differences of weight change from baseline (kg) between regular and

irregular follow-up by visits adjusted for sex and age at

surgery

Weight loss (kg): regular vs irregular follow up


Post operative

Medical Review- Annual

– Yearly

– Co morbid review

– Biochemical monitoring of nutritional status

– Bone Mineral Density

– This is dependent on the patients pre surgical result every

2- 5 years

For the rest of your life


MOS – post bariatric surgery form


MOS – patient flow

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