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