Pre & Post Operative Nursing Care of the
Bariatric Patient
Jacinta Velt
Registered Nurse
Melbourne Gastro Oesophageal Surgery | Melbourne Weight Loss Surgery
Drivers of Obesity
UK Government (2018), Foresight Obesity Map, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/296290/obesity-map-full-hi-res.pdf
Drivers of Obesity
UK Government (2017), Foresight Obesity Map, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/295153/07-1177-obesity-system-atlas.pdf
Stigma Obesity
Latner J, O’brien K.S etal., (2008) Weighing Obesity Prejudice: The Relative Strength of Different Forms of Prejudice. International Journal of Obesity 32, https://www.nature.com/articles/ijo200853
OBESITY RACE SEXUALITY
NO QUICK FIX, surgery is a TOOL
Patient Responsibility
• Accountability • Maintain & monitor baseline weight
• Dietary choices
• Lifestyle behaviours
• Exercise Behaviours
• Engage in life long follow up
Obesity
Bariatric Surgical Registry
MWLS
Op time Hosp Stay Recovery Minor Cx Major Cx Weight loss
Sleeve 45min 2 30 4% <1% 75%
RYGB 65min 2 30 8% 2% 90%
OAGB 55min 2 30 9% 4% 76%
Band 35min 1 30 7% 0% 20%
Makary et al, Arch Surg. 2010;145(8):726-731.
Surgical outcomes
Surgical Pathway
Initial Surgical Consultation
Preparation
Surgery
Hospital Care
Discharge
GP/ Specialist review
Nursing Pathway
Headspace
Medications
Hospital Care
Discharge
Education
Gastroscopy
Pathology
Dietetics
Pre-Surgery Diet
• OptiFast meal replacement product & low calories vegetables
• Typically 2 weeks
• Compliance
Post Operative Diet
Post Operative Diet
• Less ghrelin = less hunger
• Initially minimal hunger
• Meals ‘opportunity for nutrition’
• Pt’s described ‘I’m no longer constantly thinking about food
16
Moize. Obesity Surgery. 2010. Nutritional Pyramid for Post-gastric Bypass Patients
Long Term Bariatric Food Pyramid
Post OP Follow Up
1 week
1 week
1 month
3 months
6 months
9 months
Discharge12 months
Life long follow up(at MWLS)
MWLS Post Op ComplicationsSleeve RYGB SAGB
Wound haematoma 0.2%
Wound infection 0.2%
Thromboembolic event
0.2%
Anastomotic stricture 1.9%
Anastomotic leak 0.5% 1.9%
Pneumonia 0.2% 0.9%
Bleeding 0.6% 2.7%
Atelectasis 0.6% 2.3% 1.9%
N & V 2.2% 4.1% 7.4%
Malabsorption
Underweight/ Undernourished
• Very uncommon to become underweight due to weight loss surgery
• As weight drops, energy output drops too
• Eventually hit a weight plateau
Input
Output
Weight-Loss Plateau/ Homeostasis
InputOutput
Case Study
Case Study
• Respiratory: CPAP
• Orthopaedic: family history osteoarthritis*Pt 3/7 kick boxing, cycling 7 swiming
• Gastrointestinal:Band 2002, 151 kg lost 40kg, back up. Band out 2011Multiple fad diets.Failed medical management
• Psychology:Weight issue since childhood traumaStress Eating↑ post quitting smoking
• Cardiovascular:Family history : hyptertension, hyperlipidemia.
• EndocrineCurrently freezing eggsGoal: pregnancy
41 year old femaleBMI 60.2 (height 168cm, weight 170kg)
Guyenet et al Regulation of Food Intake, Energy Balance, and Body Fat Mass: Implications for the Pathogenesis and Treatment of Obesity J Clin Endocrinol Metab, March 2012, 97(3):745–755.
WeightStabilised
Lap Band Lap band failure
↑ stress eating/ snacking
• Pathology
• Gastroscope
• Fatty liver
• +/- Interventions
• +/- Physician/ Specialist Review
• Bariatric Psychologist
RYGB
Post OP Recovery
1 week Dietitian
1 week Nurse
1 monthDietitian & Nurse
3 monthsSurgeon &Dietitian
6 monthsDietitian & Nurse
9 monthsDietitian & Nurse
Portion sizes Eating time
N& VHair loss
(expected)
Hospital & Discharge
Weight Loss
13.7% 18.2%22.5%
32.5%
52.5%
Post Operative Care
• Pt coming up to 12 months post op• Pathology• USS Gall Bladder• Swap MV to Elevit• Headspace• Review diet & eating behaviours• Exercise• Commence IVF post surgical review
Questions