Orientation for Patients Considering Bariatric Surgery

Orientation for Patients Considering Bariatric Surgery

CONFIDENTIALITY ▹ Because confidentiality is essential, we expect that each person will respect and maintain the confidentiality of the orientation. What is said by individuals attending the orientation is not to be repeated or discussed at any other time or place. "What is said here - stays here."

Who attends the orientation is also confidential.

Agenda for Today’s Session •

Overview of the Disease of Obesity

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Treatment Options - Continuum of Care

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Program Overview: Orientation through Maintenance

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Next Steps

What is Obesity? “…a disease of excess fat storage with a number of associated medical illnesses” It is…

Influenced by many factors Life-long/chronic Progressive Potentially life-threatening Costly No cure

Obesity can impact quality of life & shorten it.

What is Morbid Obesity?

Clinically severe obesity is the point when serious medical conditions occur as a direct result of the obesity.

Defined as > 200 percent of ideal weight, > 100 pounds overweight, or a Body Mass Index of ≥ 40 BMI calculation =

weight (Height)2

Many Factors Influence Obesity

Co-morbid Conditions Serious illnesses that are associated with obesity: Type-2 Diabetes1,3 Hypertension1,3 Hyperlipidemia1,3 Respiratory disease1,3 Sleep apnea1,2,3 Asthma/pulmonary disorder2,3 Depression3

Menstrual irregularity2 - Amenorrhea2 - Dysmenorrhea2 Urinary stress incontinence3 Gastroesophageal reflux disease (GERD)2,3 Degenerative joint disease (DJD)3 Heart disease 2

1. NHLBI 2000 (NIH), Practical Guide: Identification, Evaluation and Treatment of Overweight and Obesity in Adults 2. NIDDK 2006 (NIH), Understanding Adult Obesity.

3. Schneider BE & Mun EC. Diabetes Care. 2005; 28:475-80

Gallstones1,2,3 Fatty liver disease2,3 Coronary artery disease1,3 Stroke1 Cancer1,3 Osteoarthritis1,2 Infertility2

Interdisciplinary Treatment Team • • • • • • •

Physician Surgeon Nurse Practitioner/Physician Assistant Psychologist/Clinical Social Worker Nutritionist Exercise Physiologist Nurse

All working together for you!

Center of Bariatric Surgery Team

Beth Ryder, MD

Program Director Bariatric Surgeon Associate Professor of Surgery

Sheenagh Bodkin, MD

Director of Obesity Medicine

Marco Giorgi, MD Bariatric Surgeon

The Miriam Hospital – Accredited Program by American College of Surgeons MBSAQIP for Adults and Adolescents



Andrew Luhrs, MD Bariatric Surgeon

All surgeons underwent specialized Fellowship training to take care of Bariatric Patients

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Elizabeth Renaud, MD

Adolescent Bariatric Surgeon Associate Professor of Surgery

Brown University Surgeons and leaders in this field

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Todd Stafford, MD

Bariatric Surgeon Associate Professor of Surgery

Team consists of resident doctors, Nurse Practitioners, Physician Assistants

Center of Bariatric Surgery Team

Kellie Armstrong, RN, MS, CBN

Elisa Wasilewski, PA

Sara Stiles RD Lead Bariatric RD

Lisha Andrew, RD

Program Manager

BSA Bariatric PA

Bariatric RD

Cristina Ruggieri, PA BSA Bariatric PA

Sara Hilsman, RD Bariatric RD

Danielle Engels

BSA Bariatric Navigator

Are You a Candidate for Weight Loss Surgery?

• Why Surgery?  95% long term (even 6 months) failure rates in traditional weight loss methods  Surgery success lasts >10 years • Who? *  Tried other methods of weight loss  At least 100 pounds over ideal body weight (BMI >40)  At least 80 pounds overweight (BMI >35) with other medical conditions eg; • • •

diabetes, high blood pressure, sleep apnea, cholesterol issues etc.

Absence of current drug and alcohol problems No uncontrolled psychological conditions Understands surgery and risks and dedicate to lifestyle modification!

*NIH consensus conference, 1991

Surgical Pathway Bariatric Patient Orientation Initial evaluation at surgeon’s office Nutrition Evaluation & Counseling

Attend at least 2 support group meetings

Psychological/Behavioral Evaluation & Counseling

Nicotine Free (2-6 months)

Insurance Approval Pre-surgical testing & teaching class Surgery Day! Follow-up medical/nutrition appointments

Attend support groups

Surgery decision by a multidisciplinary team

Timeline Depends on:

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Your type of insurance: Some require up to 6 months of requirements prior to approval for surgery. Generally, surgery occurs 2 month after insurance approval • Your ability to schedule and complete ALL evaluations and testing • Treatment for new and existing conditions identified on workup Including smoking cessation for at least 2 months & some insurance companies require longer • Decision on when and what surgery: multidisciplinary team and YOU! Not all will have surgery • Pregnancy warning: During rapid weight loss after surgery higher risk for fetal neurologic damage-avoid pregnancy for 2 years after surgery!

Nutrition Throughout Your Weight Loss Journey Pre-Operatively (“Medically Managed Weight Loss”) Number of visits based on your individual insurance • Developing healthy eating behaviors • Post-op diet • Post-op vitamin and mineral supplements • General nutrition guidelines • Meal planning

During Your Hospital Stay • Review stages of diet, vitamins and protein needs Post-Operatively • One on one visits and support groups available • Continued follow up helps to ensure your success!

• Guidance to maximize your nutrition as you reach your weight loss goals

Surgery Options

Why Have Surgery at The Miriam Hospital?

• • • • • •

Only center accredited by ASMBS/ACS joint committee (MBSAQIP) for adults and adolescents in Rhode Island Only program in Southeastern New England certified for Obesity Medicine Team with highest number of cumulative bariatric case experience in the region Six-time Magnet award for superior nursing care 24 x 7 bariatric surgeon coverage Collaborations for life-long care:

o o

Women’s Medicine Collaborative’s Healthy Way Hasbro Children’s Hospital (patients 16 years and over)

Surgery and Hospital Stay • Does insurance cover surgery?

Most insurance covers care related to bariatric surgery.

You may be responsible for copays and deductibles.

Check with your carrier!

• • •

Laparoscopic approach almost always!

General anesthesia Close monitoring by team…Nurses with expertise in bariatrics Usual length of hospital stay: o 1 overnight Usual discharge medications o Acid reducers & pain medications o Vitamins, minerals o Will adjust blood pressure or diabetes medication as needed

Bariatric Surgery Options Restriction • Adjustable Gastric Banding • Sleeve Gastrectomy Combination malabsorptive and restrictive • Roux-en-Y Gastric Bypass • Duodenal Switch Re-visional Surgery

Restrictive Procedures A small pouch is created, which limits the amount of food patients can eat.

The smaller stomach pouch fills quickly, helping patients feel satisfied with less food.

Examples of restrictive bariatric procedures: Gastric Banding Gastric Sleeve

Adjustable Gastric Banding •

Laparoscopic

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Mean excess weight loss at one year of 30-40%

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Requires implanted medical device

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Lowest rate of complications

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Need frequent doctor appointments to adjust band

Gastric Banding Complications •

Nausea/Vomiting

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Band Erosion

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Band Slips

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Esophageal Dysmotility

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Intolerance

Sleeve Gastrectomy •

Laparoscopic approach

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Mean excess weight loss at one year 30-50%

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No implanted devices

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No rerouting of the intestines.

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Cannot be reversed!

3-5 oz. sleeve

r e m o v e d

Risks and Complications of Gastric Sleeve • • • • • • • •

Wound infection Narrowing of stomach Bleeding Deep Vein Thrombosis (DVT) – Vein clots Pulmonary Embolism Leakage of staple line Reflux and vomiting Since this procedure is relatively newer, 10 year and beyond risks and benefits are not well-known.

Combination Procedure •

The surgeon creates a small pouch, limiting the amount of food a patient can eat.

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A section of the small intestine is rerouted, causing food to bypass a large portion of the small intestine.

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Bypassing a portion of the small intestine means the patient’s body absorbs fewer calories.

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Gastric Bypass is an example of a combination procedure

Roux-en-Y Gastric Bypass •

Laparoscopic approach

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Also called Gastric Bypass

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Mean excess weight loss at 1.5 years 60-70 %

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No implanted medical device

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Not removing large portion of stomach like sleeve: it’s just bypassed and intestines are reconnected

Gastric Bypass Complications • • • • • • • • •

Gastrointestinal Leak Narrowing or Obstruction at connections Bleeding after surgery Deep Vein Thrombosis (DVT) – blood clots Pulmonary Embolism Intestinal Obstruction Malabsorption (vitamins, iron, calcium can lead to anemia , hair loss, fracture) Inability easily endoscope divided stomach Dumping Syndrome

Duodenal Switch •

Duodenal switch is a procedure performed by removing the left portion of the stomach to limit food intake and then “switching” the small intestine around to alter the digestion process and limit food absorption.

How it works •

Reduced stomach capacity

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Longer bypass as compared to gastric bypass (roughly three quarters of intestines bypassed)

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Results in weight loss from both restriction and malabsorption

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DS initially helps to reduce the amount of food that is consumed (over time this effect lessens)

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Food does not mix with the bile and pancreatic enzymes until very far down the small intestine

Duodenal Switch Disadvantages

Advantages

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Results greater weight loss than Gastric Bypass or Sleeve Gastrectomy

 • • •

70% or greater percent excess weight loss, at 5 year follow up

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Reduces the absorption of fat by 70% or more Causes favorable changes in gut hormones to reduce appetite Is the most effective against diabetes compared to Gastric Bypass and Sleeve Gastrectomy

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Longest operation: greater than 4 hours May have higher complication rates Greater potential to cause protein deficiencies and long-term deficiencies of a number of vitamins and minerals. Vitamins

may cost as much as $120 per month.

Compliance with follow-up visits and care and strict adherence to dietary and vitamin supplementation guidelines are critical to avoiding serious complications from protein and certain vitamin deficiencies

Long Term Results Procedure

% EWL

Sleeve Gastrectomy

50-60%

Gastric Bypass

60-80%

Duodenal Switch

70-90%

Type 2 Diabetes Remission Procedure Medical Therapy

2-year Remission Rate 0-45%

Sleeve Gastrectomy

50-60%

Gastric Bypass

60-80%

Duodenal Switch

85-98%

All Bariatric Surgery Complications • • • • • • •

GI Leak Stricture Bleeding DVT Wound Infection Pulmonary Embolism Death

0.6% 0.6% 0.6% 0.2 % 0.1% 0.4% 0.13%

May need emergency reoperations/transfusions/ longer hospital stay/cause disability or death

Bariatric Surgery Effectiveness in Curing Medical Conditions What is the impact of bariatric surgery?

In a US/Canadian study > 6700 patients with long term for other serious illnesses

• • • •

Diabetes Sleep apnea High Blood Pressure High cholesterol

83 % Resolution 80 % Resolution 67 % Resolution 90 % Resolution

Type 2 diabetes mellitus long term remission rate – 60% following surgery 70 60 50 40 30 20 10 0

T2DM remission in observational studies Conventional Rx

T2DM remission in RCT Bariatric Rx

Bariatric Surgery Improves Life Expectancy Reference

Follow-up Duration

Decrease in Mortality

MacDonald et.al.

9 years

88%

Flum et.al.

4.4 years

33%

Christou et.al.

5 years

89%

O’Brien et.al.

12 years

73%

Sowemimo et.al.

4.4 years

50%

Adams et.al.

7.1 years

40%

Sjostrom et.al.

14 years

31%

Bariatric Surgery Has Low Incidence of Death – It Beats out Gallbladder Surgery 3.5 3 2.5 2 1.5 1 0.5 0 Bariatric Surgery .13%

Lap Chole .52%

Hip Replacement .93% Mortality Rates (%)

CABG 3.30%

Is It More Dangerous Not to Operate? Weight loss surgery results in 89% reduction in risk of death over 5 years compared to yo-yo dieting!

7.0 6.0 5.0 4.0 3.0 2.0 1.0 0.0

Bariatric* .68%

Controls 6.17% Mortality Rates (%)

* Includes perioperative (30-day) mortality of 0.4%. p-value 0.001 Christou NV, Sampalis, JS, Liberman M, et al. Surgery Decreases Long-Term Mortality, Morbidity, and Health Care Use in Morbidly Obese Patients. Annals of Surgery 2004;240(3):416-424.

Center for Bariatric Surgery Resources Bariatric Support Groups/Contacts Kellie Armstrong, RN, MS, CBN, Bariatric Manager Bariatric Registered Dieticians Center for Bariatric Surgery Hotline: (401) 793-3922

Lifespan.org/centers-services/center-bariatric-surgery

Surgeon’s Office: (401) 272-1800

Now onto the Next Steps!

Step Two: Comprehensive Evaluation

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Medical Lifestyle/Behavioral Nutrition Exercise

Our team is ready to work together with you to help you safely achieve long-term, weight management!

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We look forward to helping improve your future using surgery as a tool.

It is not a cure!

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Obesity is a life-long struggle and demands long-term commitment and lifestyle changes.

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Please bring any questions you may have to your consult at your surgeon’s office.

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Visit us: www.lifespan.org/centers-services/center-bariatric-surgery

Thank You!

The Center for Bariatric Surgery is located at The Miriam Hospital

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