Patient selection, perioperative management, and post-operative care
What if we told you there was a powerful tool that could help promote significant weight loss, correct uncontrolled diabetes, improve quality of life, and even improve patient mortality? What if we told you it was offered less than 1% of the time to patients who qualify for it? Listen as our esteemed guest Dr. Vivan Sanchez (Boston University) talks us through the patient selection, preoperative workup, and postoperative considerations for bariatric surgery, and how it might benefit your patients.
Credits
Written and Produced by: Paul Williams MD, FACP
Infographic: Edison Jyang
Cover Art: Edison Jyang
Hosts: Stuart Brigham MD; Matthew Watto MD, FACP; Paul Williams MD, FACP
Editor: Molly Heublein, MD; Clair Morgan of nodderly.com
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CME Partner: VCU Health CE
The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit.
Show Segments
Intro, disclaimer, guest bio
Guest one-liner
Picks of the Week*
Case from Kashlak
Criteria for bariatric surgery
Benefits of bariatric surgery
Presurgical workup
Postoperative management
Complications
Outro
Bariatric Surgery Pearls
Selection of bariatric surgery patients is largely based on a BMI > 40 or > 35 with major comorbidities
Bariatric surgery has become increasingly recognized as an important tool in managing uncontrolled diabetes
Under 1% of patients with morbid obesity undergo bariatric surgery, despite a perioperative mortality less than 1%
While long-term success of medical weight loss is poor, metabolic surgery can lead to excess weight loss of 60-70%
The American Society for Metabolic & Bariatric Surgery has clear guidelines for preoperative evaluation, including specific lab tests and specialist evaluation
In the immediate postoperative period, extended release medications should be converted to immediate release, and dose adjustments may be needed for diabetes, thyroid, and blood pressure medications
Oral NSAIDs should be avoided following bariatric surgery
Postoperative complications of bariatric surgery include micronutrient deficiencies, symptomatic cholelithiasis, dumping syndrome, Barrett’s esophagus, and regain of weight
In 2016, 2nd Diabetes Surgery Summit (DSS – II) recommended that patients with BMI 30-35 should be considered if diabetes is poorly controlled despite medication.
In Asian populations, could consider metabolic surgery at 2.5 points below these cutoffs
Same comorbidities appear to occur at a lower BMI point
Under 1% of patients who are morbidly obese undergo bariatric surgery
Patients may perceive elevated mortality risk
In centers of excellence, perioperative mortality under 1% (ASMBS 2018)
Patients may also be concerned that postoperative lifestyle changes are untenable
In under 3 months, most patients can eat majority of foods they ate pre-operatively
Benefits of Metabolic Surgery
Long-term success of medical weight loss is generally poor
Metabolic surgery has much better long-term efficacy for weight loss
Varies by procedure, but excess weight loss can range from 60-70%
Patients can expect improvements in quality of life and mortality
Can also see metabolic changes shortly after surgeries are performed
Exact mechanisms not well-understood
Patients with diabetes can sometimes be discharged off of diabetes medications
Preoperative evaluation for metabolic surgery
The American Society for Metabolic & Bariatric Surgery has clear guidelines for preoperative evaluation
Patient to see experienced surgeon, meet with a nutritionist and a behavioral psychologist, and will have their risk factors mitigated
Laparoscopic sleeve gastrectomy and roux-en-y bypass surgeries are the most commonly offered
Roux-en-y
Usually done laparoscopically
Stomach divided into remnant and a smaller gastric pouch. The small intestine is divided, with one limb connected to the gastric pouch and connected distally to a jejuno-jejunal anastomosis
Laparoscopic sleeve gastrectomy
Stomach is divided using staples
Has metabolic effects beyond simple restriction
Severe reflux may be a contraindication for sleeve gastrectomy
Initial lab work usually includes CBC, BMP, iron studies, lipid panel, TSH, and Hgb A1c
Patients typically evaluated for OSA, and may be referred for Cardiology for risk stratification, Gastroenterology for endoscopic evaluation, or Endocrinology for optimization of diabetes
Nutrition can be viewed as the base of preoperative optimization
Behavioral health evaluation done to evaluate for substance use, disordered eating, or significant mood disorder that may impact care
High incidence of depression in patients with obesity
If food is used as a compensatory mechanism, this may be transferred to substance use or other outlets postoperatively
Preoperative weight loss often mandated by insurance companies
Idea is to improve intraoperative and postoperative outcomes
This is not supported by evidence and may serve as a barrier
Postoperative management after metabolic surgery
In the short term, typically advanced from clear liquids to full liquids to soft foods
Often program-specific and dependent upon procedure
Alcohol intake should be restricted, as should carbonated beverages
Extended release medications should be switched to immediate release
Often done preoperatively
Antihypertensives, diabetes medications, and thyroid medications may need adjusted postoperatively
NSAIDs must be avoided postoperatively due to the increased risk of marginal ulceration
Pregnancy should be avoided for the first year or two after the procedure
Contraceptive counseling should be provided
Underlying endocrinopathies may be corrected by surgery and lead to increased fertility
The weight loss and potential vitamin deficiencies may lead to pregnancy complications
Multivitamin with iron, calcium, and B12 supplementation recommended postoperatively
Often part of an order set, but patients can take child’s multivitamin
With gastric bypass, may use vitamin C to aid absorption of iron, which is impaired due to changes in gastric pH and surgical changes of the duodenum
Bypass surgeries can also lead to other micronutrient deficiencies
With the sleeve gastrectomy, anemia is most common nutritional complication
Nutritional labs may eventually fall to the primary care physician
Include B12, folic acid (RBC folic acid optional), iron studies, 25-vitamin D, iPTH, and Vitamin A (Mechanik 2020)
Thiamine, copper, zinc, and selenium evaluation are recommended if there are findings consistent with deficiency
Potential complications of metabolic surgery
Postoperative patients are at increased risk for symptomatic cholelithiasis
Gastric bypass in the postoperative period with acute onset abdominal pain should be referred for urgent evaluation
Can herald hernia, dilated remnant, or ulcer
Gastric sleeve patients can develop worsening reflux or de novo Barrett’s esophagus (Qumseya 2021)
Dr. Sanchez recommends upper endoscopy 3 years after the sleeve procedure even in the absence of reflux symptoms
Dumping syndrome can also occur postoperatively with gastric bypass
Generally occurs after high carbohydrate intake
Early dumping (30-60 minutes after eating) is associated with cramping, nausea, flushing, and palpitations
Attributed to fluid shifts and gut hormonal changes
Late dumping (1-3 hours after eating) is associated with fatigue, flushing, dizziness and palpitations
Thought to be due to blood sugar changes
Managed by eating more complex carbohydrates, increasing fiber and hydration, and eating small meals
Patients with weight regain postoperatively should be re-connected to Nutrition and Behavioral Health
Goal
Listeners will recognize appropriate indications for metabolic surgery, as well as preoperative and postoperative management of commonly offered bariatric surgeries.
Learning objectives
After listening to this episode listeners will…
Outline the potential indications for bariatric surgery
Explain the potential patient benefits of bariatric surgery
Discuss the recommended preoperative evaluation for patients considering metabolic surgery
Recognize the most common types of bariatric surgery offered to patients
Describe the key elements of postoperative medication and diet management of bariatric surgery management
Identify potential postoperative complications of bariatric surgery
Disclosures
Dr. Sanchez reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
Citation
Sanchez V, Williams PN, Watto MF, Brigham S. “#275 Bariatric Surgery with Vivian Sanchez”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list May 24, 2021.
What a great coincidence. I am teaching a lecture on Bariatric Surgery for Family Medicine to my residents tomorrow. Your episode on bariatric surgery was really helpful. Thanks!
CME Partner
The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit.
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Comments
What a great coincidence. I am teaching a lecture on Bariatric Surgery for Family Medicine to my residents tomorrow. Your episode on bariatric surgery was really helpful. Thanks!