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Preoperative evaluation of the Bariatric patient.

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Preoperative evaluation of the Bariatric patient. William Bakhos,MD Psychological Evaluation Accountability Stability - Will surgery disrupt it? – PowerPoint PPT presentation

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Title: Preoperative evaluation of the Bariatric patient.


1
Preoperative evaluation of the Bariatric patient.
  • William Bakhos,MD

2
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3
Preoperative Focus Multidirectional
  • Concomitant patient education
  • Informed consent
  • Medical evaluation for risk assessment
  • Strategies for risk reduction

4
Patient Education Content
  • Health risks and medical hazards associated with
    obesity.
  • Quality of life issues.
  • Low probability of success with dietary or other
    non-surgical weight control programs.
  • Weight loss results of surgery, including failure
    rates of the different types of procedures
  • Impact of weight loss.
  • Necessity for long-term follow-up.

5
Patient Education Content
  • Possible complications
  • Mechanisms for weight loss
  • Post-operative alcohol restriction
  • Available and accepted operations for obesity
    treatment,results,advantages,disadvantages,
    operative risks and complications
  • Mortality rate (broken down by BMI and severe
    medical problems)

6
Contraindications to Surgery
  • High medical risk.
  • Unable to understand the operation.
  • Unrealistic expectations.
  • Unresolved emotional illness.
  • Drug abuse/alcoholism.
  • Unwilling to sign follow-up contract.
  • Does not have a support person.

7
Initial Screening
  • HP- Medical and Surgical History
  • Family History/Social History
  • Medications/Allergies
  • Diet History
  • Physical Exam- HT, WT, BMI, VS

8
Initial Screening
  • Labs
  • Chemistry, liver function, renal function
  • Lipid Profile
  • CBC
  • Iron Profile- TIBC, total iron, saturation
  • B-1, B-12 levels
  • HbA1c
  • H-Pylori
  • Drug Screen (optional)

9
Initial Screening
  • Radiology
  • U/S liver/GB
  • CXR
  • UGI Swallow Study (optional)
  • Cardiac
  • EKG
  • Venous Doppler Studies (optional)

10
Preoperative Evaluations
  • ASBS and SAGES Guidelines For Surgical
  • Treatment Bariatric Surgery, Published in
    2000
  • The multidisciplinary approach includes
  • Medical management of comorbidities
  • Dietary instruction,
  • Exercise training,
  • Specialized nursing care and psychological
    assistance as needed.
  • Having a multidisciplinary team who can
    address these necessary components of bariatric
    patients needs is imperative.

11
Preoperative Behavior Change
  • Preoperative exercise program.
  • Patients sometimes asked to maintain body weight
    or lose weight prior to surgery.
  • Patients asked to quit smoking prior to surgery.
  • Reduces risk, establishes healthy habits,and
    tests motivaiton and commitment.

12
Dietary Evaluation
  • Registered Dietitian
  • Address dietary concerns and begin making changes
    now
  • Avoid the Last Supper Syndrome
  • Diabetes Education

13
Exercise Evaluation
  • Preoperative exercise program.
  • Assessment .
  • Mobility Issues.
  • Physical Conditioning.
  • Education.
  • Motivation.

14
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15
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16
Gastro-Intestinal Evaluation.
  • Endoscopy.
  • Ulcers (Helicobacter pylori).
  • Esophageal Disorders.
  • Irritable Bowel Syndrome.
  • Crohns Disease.

17
Birth control counseling.
  • Absence of pregnancy.
  • Birth control.
  • Risky pregnancy in the early post-op. period (1-2
    years).
  • Weight loss may improve fertility.

18
Cardiac Risk Complication Rate
  • One point assigned per risk factor
  • 1- CAD
  • 2- CHF
  • 3- CVD
  • 4- High-risk surgery
  • 5- Diabetic requiring insulin
  • 6- Pre-op creatinine gt2.0 mg/dl
  • Risk Class/ complication rate
  • Class I Zero 0.4
  • Class II One 0.9
  • Class III Two 6.6
  • Class IV Three 11.0

Lee TH,
et al. Circulation. 19991001043-49
19
Cardiac Risk Assessment.
  • Stress Testing
  • Echocardiogram
  • Medication adjustment
  • Cardiac Clearance

20
Beta BlockadeMajor criteria
  • Use Beta-blockers in patients meeting any of
    the following criteria
  • History of MI,current angina Or use of sublingual
    nitroglycerine
  • Positive exercise test results
  • Q waves on ECG
  • Patients who have undergone PTCA or CABG and who
    have chest pain
  • History of TIA or CVA
  • Diabetes mellitus requiring insulin therapy
  • Chronic renal insufficiency, defined as a
    baseline creatinine level of at least 2.0 mg/dL
    (177 µmol/L)
  • Lee TH et al. Derivation and prospective
    validation of a simple index for prediction of
    cardiac risk of major noncardiac surgery.
    Circulation. 19991001043-1049.

21
Beta BlockadeMinor Criteria
  • Use Beta -blockers in patients meeting any 2
    of the following criteria
  • Aged 65 years or older
  • Hypertension
  • Current smoker
  • Serum cholesterol concentration at least 240
    mg/dL (6.2 mmol/L)
  • Diabetes mellitus not requiring insulin therapy
  • Mangano et al. Effect of atenolol on
    mortality and cardiovascular morbidity after
    noncardiac surgery Multicenter Study of
    Perioperative Ischemia Research Group. N Engl J
    Med. 19963351713-1720.

22
Pulmonary Evaluation.
  • Obstructive Sleep Apnea (testing and treatment).
  • Asthma.
  • Smokers.

23
Endocrine Evaluation
  • Diabetes Management.
  • Diabetes Education.
  • Thyroid disease.

24
DVT Prophylaxis
  • Early ambulation
  • Elastic stockings
  • Intermittent pneumatic compression devices IPC
  • Inferior vena caval filters
  • Low Dose Unfractionated Heparin
  • Low Molecular Weight Heparin (LMWH)

25
IVC Filter placement
  • Preoperative vena caval filter placement should
    be considered in bariatric patients with
  • Prior pulmonary embolus
  • Prior deep venous thrombosis
  • Evidence of venous stasis
  • Known hypercoagulable state.
  • Keeling WB et al..Current indications for
    preoperative inferior vena cava filter insertion
    in patients undergoing surgery for morbid
    obesity. Obes Surg. 2005 Aug15(7)1009-12

26
Pre-Operative Visit
  • Physical Exam.
  • Changes to medications, condition, VS, WT, BMI.
  • Check all Consult Notes.
  • Photographs (optional).
  • Educational Assessment Tools.
  • Consents.

27
Pre-Operative Visit
  • Preoperative Instructions
  • Verbal and Written
  • Be Explicit
  • Bowel Prep

28
Pre-Operative Visit Patient Education
  • Pre-admission orders including any bowel
    preparation,meal restrictions, NPO instructions
  • When to arrive at the hospital and what to bring
  • What will take place prior to surgery
  • Waking up in the PACU after the operation and the
    importance of early ambulation
  • Pain management
  • Introduction of fluids and diet progression

29
Pre-Operative Visit Patient Education
  • Maximizes the patients success potential.
  • Decreases stress from lack of knowledge
  • Helps Set appropriate expectations.

30
Pre-Operative Visit Prophylactic ABx
  • First Generation cephalosporin before induction
    and 12 hours post-op.
  • Vancomycin if allergic to penicillin.
  • Same as any UGI Procedure.

31
Pre-Operative Visit Preo-op Diet
  • Low calorie,Low carb,High protein liquids for 2
    weeks pre-op.
  • Helps control blood sugar peri-op.
  • Technically helps with the size of the liver.

32
Information Meetings/Support Groups.
  • Help consolidate the informations about peri-op
    expectations and care.
  • Focus on the change in lifestyle and commitment
    for better results.
  • Sharing personal experience.

33
Psychological Evaluation
  • The psychological evaluation can be used to
    identify psychiatric disorders, provide treatment
    referrals, and flag any contraindications for
    surgery.
  • It also provides an opportunity to educate
    patients, resolve ambivalence, and build
    motivation.

34
Psychological Evaluation
  • Accountability
  • Stability - Will surgery disrupt it?
  • Situational vs. clinical depression(treated/untrea
    ted)
  • pre op treatment)
  • History of eating disorders
  • Anorexia/Bulimia
  • Absence of mental illness
  • Setting goals realistic expectations
  • Support system
  • Ability willingness to make lifetime changes
  • Safe setting (domestic dynamics)
  • Substance abuse
  • Suicide attempts

35
Psychological EvaluationPatient History
  • History of any psychiatric problems.
  • History of dieting and binge eating.
  • Results of any previous evaluations or treatment.
  • Previous weight loss attempts.
  • Relevant personal and family information.
  • Medication and dietary supplements.

36
Psychological Evaluation Patient Knowledge Gaps
  • A significant minority of patients
  • - Believe that surgery makes it impossible to
    overeat (25).
  • - Have unrealistic weight loss expectations (19
    high and 30 low).
  • - Do not know the symptoms of dumping (gt20).
  • - Believe there is no need to worry if
    depression occurred in the postoperative period
    (27).
  • Gonder-Frederick et. al., Bariatric Times,
    Nov./Dec. 2004

37
Psychological Evaluation Possible
contraindications for surgery
  • Concerns about patients ability to give informed
    consent or comply with behavior changes required
    after operation.
  • Current severe or uncontrolled psychopathology
    such as alcoholism, schizophrenia, or bipolar
    disorder

38
Psychological Evaluation Possible
contraindications for surgery
  • patients who have ever had an Axis I clinical
    disorder, especially mood or anxiety, exhibit
    poorer weight outcomes 6 months after gastric
    bypass than those who have never had an Axis I
    disorder.
  • Kalarchian MA et al..Surg Obes Relat Dis. 2008
    Jul-Aug4(4)544-9

39
Psychological Evaluation Patient Goals and
Expectations
  • Some patients may have unrealistic goals and
    expectations for weight loss.
  • Personal goals and expectations may affect
    success at long-term weight control.
  • The behavioral health provider may provide
    psychoeducation, foster realistic expectations,
    and build motivation.

40
Psychological Evaluation Treatment
Recommendations
  • Empirically supported treatments exist for
    many psychiatric disorders potentially relevant
    to the bariatric surgery patient.
  • Eating disorders (e.g., binge eating).
  • Mood disorders (e.g., depression).
  • Anxiety disorders.
  • Borderline personality disorder.

41
Psychological Evaluation What Psychologists can
do ?
  • Screen out inappropriate patients.
  • Evidence not promising research is needed
  • Active substance abuse, psychiatric personality
    disorder, suicide ideation
  • Teaching candidates to be good patients.
  • Attend support groups, reading, learning
  • What constitutes a good patient?

42
Psychological Evaluation Possible Complicating
Factors
  • Poorly managed psychopathology
  • Depression, Anxiety, Bi-polar, Bulimia etc..
  • Borderline personality disorder
  • Active alcohol or substance abuse
  • Recent hospitalization (mental disorder)
  • History of postoperative complications

43
Psychological Evaluation Possible Positive
Predictors or Factors
  • Social/Emotional support network
  • Family, Friends.
  • Optimism, positive attitude
  • Humor
  • Knowledge of surgery, diet, etc..
  • Compliance may be the best indicator of
    successful outcome

44
Psychological Evaluation What Pre-Ops Want ?
  • ? Self-esteem
  • ? Energy
  • ? Happiness, optimism
  • ? Depression
  • ? Physical symptoms
  • ? Medications

45
Patients Report Dramatic Changes After Surgery
  • Able to breathe easily.
  • Able to sleep wake up refreshed.
  • Free from snoring apnea.
  • Off most pre-op meds.
  • Free from joint pain.
  • More active and less fatigued
  • Resolution of chronic issues like skin rashes.
  • Relief from depression
  • Excited to start a new day
  • Happy to look in the mirror when getting ready
    for work
  • Experienced improvement in work arena, i.e.
    promotion, new duties, raises etc.
  • Able to pursue new hobbies and interests.
  • Self confident.

46
Psychological Evaluation What Post-ops Get ?
  • Positives Psychological
  • ? Self esteem
  • ? Happiness, optimism
  • ? Body image
  • ? Emotional access
  • ? Depression
  • ? Food obsession

47
Psychological Evaluation What Post-ops Get ?
  • Positives Social
  • ? Going out, trying new activities
  • ? Socializing
  • ? Intimacy
  • ? Sex, libido
  • ? Dating, flirting

48
Psychological Evaluation What Post-ops Get ?
  • Positives Physical
  • ? Health (general)
  • ? Energy
  • ? Mobility (activities of daily living)
  • ? Physical symptoms (sleep dsrpt, arthritis)
  • ? Clothing

49
Psychological Evaluation Psychosocial Outcomes
  • Improvements in social relations and employment.
  • Reductions in depression and anxiety.
  • Decreases in binge eating.
  • Herpertz et. al, 2003 Bocchieri et. al,
    2002

50
ConclusionClinical Decision Making
  • There are no well-established predictors of
    surgery outcome.
  • There are few alternative treatments for
    individuals who qualify for surgery

51
Conclusion Decisional Balance
  • CONS
  • Potential for complications.
  • Careful medical monitoring for life
  • Miss time from work
  • Feeling like a failure.
  • PROS
  • Long-term weight control.
  • Ill have a tool to help. me eat less food at
    each meal.
  • Perform better at my job.
  • Helps improve my diabetes and reduce my
    medications.

52
Postoperative Eating Problems
  • Although surgery has a positive impact
    overall,some patients do experience the onset of
    eating disorders after bariatric surgery (or
    other behavioral health concerns).
  • Eating disorders may be most common among those
    who had binge eating or other eating problems
    prior to operation.
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