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Bariatric Surgery

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Malabsorption of nutrients creates greater weight loss. Resolution of comorbid factors ... Looked at weight loss of patients in follow-up over 5 years ... – PowerPoint PPT presentation

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Title: Bariatric Surgery


1
Bariatric Surgery
  • Christina R Pruemer, B.S.

2
Purpose
  • To make dietetics professionals aware of the
    types of bariatric surgery, the benefits and
    risks associated with the procedures, and related
    nutrition and weight loss concerns.

3
Overview
  • Obesity
  • History of bariatric surgery
  • Types of bariatric surgery
  • Complications/nutrition concerns
  • benefits/weight loss
  • Studies
  • Disease states
  • Reinvented procedures
  • Conclusions

4
Defining obesity
  • Overweight
  • BMI 25
  • Obesity
  • BMI 30

5
Obesity worldwide
  • More than 1 billion overweight adults
  • 300 million obese adults
  • Highest BMIs
  • North America
  • Europe
  • Latin American
  • North Africa
  • Pacific Island

6
Obesity Trends Among U.S. AdultsBRFSS, 1991-2002
(BMI 30, or 30 lbs overweight for 5 4 woman)
2002
No Data 1519 2024 25
7
Digestive system
8
Bariatrics
  • Defined
  • Branch of medicine that deals with prevention,
    control, and treatment of obesity
  • Bariatric surgery
  • Uses surgical means to control and treat obesity

9
Where we have been
  • 1950s
  • Noted that those with short bowel syndrome lost
    weight.
  • Led to use in treatment of obesity
  • Jejuno-colic bypass
  • Fluid and electrolyte imbalances, liver
    dysfunction
  • Abandoned

10
Where we have been, cont
  • 1960s-1970s
  • Jejuno-ileal bypass
  • Subsequent development of gastric restriction
  • Many people are living because of the surgery
  • Mortality also resulted
  • Largely abandoned in the United States

11
Where we have been, cont
  • Mid-Late 1970s
  • Masons Horizontal gastroplasty
  • 1980s
  • Ballooning
  • Inserted endoscopically and inflated with air
  • Weight loss was temporary
  • Problems
  • Pressure ulcers
  • Deflation
  • Placement problems

12
Selection criteria
  • BMI
  • 40
  • 35 with comorbid conditions
  • Diabetes
  • Cardiovascular disease
  • Others
  • Eating disorders
  • Pregnancy
  • Age(over 18)

13
(No Transcript)
14
Bariatric Surgery
  • 2 types
  • Restrictive (15-30ml pouch)
  • Vertical Banded Gastroplasty
  • Malabsorptive
  • Roux-en-Y gastric bypass
  • Biliopancreatic diversion
  • Goal
  • Loss of excess body weight

15
Restrictive procedures
  • Vertical Banded Gastroplasty

16
Vertical Banded Gastroplasty
17
Malabsorptive procedures
  • Roux-en-Y Gastric Bypass
  • Bilipancreatic Diversion

18
Masons Roux-en-Y gastric bypass
19
Roux-en-Y gastric bypass
Y
20
Scopinaros Biliopancreatic diversionBiliopancrea
tic diversion with duodenal switch
21
Complications with restrictive procedures
  • Overeating
  • Pouch stretches
  • Staple disruption
  • Staple failure significantly reduced with use of
    4 line staple as opposed to single line
  • Pouch obstruction
  • Death-0.4, reoperation-0.65, wound
    infection-2.13, pulmonary embolism-0.13

22
Nutrition for restrictive procedures
  • Protein calorie malnutrition
  • Only with excessive vomiting or refusal to eat
  • Supplements
  • Vitamin/mineral supplements sufficient
  • No malabsorption of specific nutrients

23
Complications with malabsorptive procedures
  • Overeating
  • Pouch stretches
  • Staple line ruptures
  • Dumping syndrome
  • Abdominal hernia
  • Biliopancreatic limb obstruction
  • Rare, usually long after initial operation

24
Nutrition concernswith malabsorptive procedures
  • Protein malnutrition
  • Fat malabsorption
  • Affects fat soluble vitamins
  • Vitamin/mineral deficiencies
  • Iron
  • B12
  • Folate
  • Calcium
  • Vitamin D
  • Malabsorption
  • Meat/milk products not well tolerated

25
Benefits of restrictive procedures
  • Limited malabsorption of nutrients
  • Fewer complications (especially long term)

26
Benefits of malabsorptive procedures
  • Malabsorption of nutrients creates greater weight
    loss
  • Resolution of comorbid factors

27
Success
  • 50 loss of excess body weight, maintained over 5
    years
  • Vertical banded gastroplasty
  • Average loss of 40 excess weight
  • Malabsorptive procedures
  • Average loss of 60-70 excess weight
  • 30 of patients gain weight at 18 months to 2
    years after surgery

28
Studies
29
Brolin RE, et al, 1998
  • Subjects
  • Menstruating women
  • 29 experimental, 27 control
  • Design
  • Prospective, double-blind, randomized study
  • All received standard multivitamin
  • Given iron supplement or placebo beginning 1
    month after RYGB
  • Followed for 2 years
  • Tested ferritin, hemoglobin, hematocrit, TIBC

30
Results
31
Behrns KE, et al, 1994
  • Study on Vitamin B12
  • 8 patients after RYGB
  • Measured cobalamin absorption prior to surgery
    and 6-8 weeks after
  • Results
  • Postoperative absorption significantly decreased
  • Recommendation
  • Monthly parenteral injection or
  • Daily supplement of non-protein bound cobalamin

32
Brolin RE, et al, 1994
  • Brolin, et al, 1994
  • 138 patients
  • 30 VBG
  • 108 RYGB

33
Brolin, 1994, cont
  • Brolin, cont.
  • Nutritional deficiencies
  • VBG 0
  • RYGB
  • 30 cases B12
  • 30 cases iron
  • 2 cases folate
  • Oral supplements
  • 2 iron deficiencies required injection
  • Weight loss
  • VBG 40 success rate
  • RYGB 92 success rate

34
Skroubis G, et al, 2002
  • Subjects
  • 79 RYGB
  • 95 BPD (modified)
  • All received multivitamin supplement
  • Looked at weight loss of patients in follow-up
    over 5 years

35
Skroubis G, cont
36
Skroubis G, cont
  • Other results
  • Low ferritin
  • RYGP-37.7
  • BPD-15.2
  • Estimate B12 deficiencies most likely at 10.7
    months following RYGB and 7.9 following BPD
  • Folic acid was not supplemented, was not
    deficient
  • Does folic acid require supplementation?

37
Moize V, et al, 2003
  • Calorie and protein intake in 93 patients who had
    RYGB, taking multivitamin, iron, and calcium
  • Results
  • Drastic reduction in calories (increased over 12 months
  • Insufficient protein intake over 12 months
  • No significant changes in albumin, vitamin B12,
    hemoglobin, or mean corpuscular volume
  • Iron levels increased from 3-12 months
  • Anemia
  • 3 months 5 patients
  • 6 months 6 patients
  • 12 months 5 patients

38
Moize V, cont
  • Food intolerances
  • Meat/eggs
  • Rice/pasta/bread
  • Vegetables
  • Milk
  • Higher food intolerances led to decreased intake
  • Discussion
  • Modular protein supplementation

39
Martinez MJ, et al, 2003
  • Subjects
  • 15 RYGB
  • 47 BPD
  • TPN (38 patients) and no nutritional support (24
    patients)
  • Compared serum albumin, length of hospital stay,
    number of infections
  • Results
  • No difference in nutritional status or infection
  • Hospital stay was decreased with no parenteral
    nutrition

40
Disease states
41
General benefits of weight loss
  • Improvements in
  • Blood glucose control for Type 2 DM
  • Lipid profiles
  • Hypertension
  • Arthritis
  • Cardiac function
  • Respiratory function
  • Urinary stress incontinence
  • Sleep apnea
  • Decreased health care costs

42
Reinvented procedures
  • Intragastric balloon
  • Gastric banding

43
BioEnterics Intragastric Balloon
44
Totté E, et al, 2001
  • 126 patients, 500ml saline inflation, 800 Kcal
    diet restriction, removed after 3-6 months
  • Complications
  • Severe nausea (up to 1 month post)
  • 76
  • Treated with anti-emetic drugs
  • Intolerant to device
  • 4
  • Gastric perforation along greater curvature of
    stomach
  • 4

45
Totté, cont
  • Weight loss
  • 48.6 excess weight at 3 months
  • 50.8 total maximum loss
  • Mean loss of 18 kg with dietary compliance
  • Mean loss of 9.6 kg without dietary compliance
  • Satisfaction was very low
  • 8.8 unsatisfied
  • 40 very unsatisfied

46
Gastric Banding
47
Conclusions
  • Supplement all procedures with multivitamin
  • Supplement malabsorptive procedures with iron,
    B12, and Calcium at least
  • Thoroughly educate patients on diet regimen
  • Make sure patients understand the
    results/consequences
  • Noncompliance will result is decreased weight
    loss, nausea/vomiting, possible need for plastic
    surgery, and others
  • Follow a multi-disciplinary approach

48
Diet regimen
  • Start with clear liquids for lunch next day
  • Soft blended diet for next two weeks as tolerated
  • Advance to textured food over next 10 weeks as
    tolerated
  • Take multivitamin, iron, calcium supplements

49
Conclusions, cont
  • Future
  • Increase in obesity
  • Increase in bariatric surgery
  • This is not a miracle cure for obesity

50
Questions?
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