Perioperative Perioperative Care of the Care of the

Bariatric PatientBariatric PatientMark Kadowaki, MD, FACSMark Kadowaki, MD, FACS

Wellmont Surgical ServicesWellmont Surgical Services

Kingsport, TenesseeKingsport, Tenessee

ObjectivesObjectives

Be familiar with the perioperative Be familiar with the perioperative concerns that face the bariatric concerns that face the bariatric patientpatient

Be aware of the signs of complications Be aware of the signs of complications after bariatric surgeryafter bariatric surgery

Plan for initial management and Plan for initial management and stabilization of the patient suffering stabilization of the patient suffering postoperative complicationspostoperative complications

Bariatric ProceduresBariatric Procedures

WWW.ASMBS.ORGWWW.ASMBS.ORG Bariatric Surgery: Postoperative ConcernsBariatric Surgery: Postoperative Concerns

http://s3.amazonaws.com/publicASMBS/Guidelihttp://s3.amazonaws.com/publicASMBS/GuidelinesStatements/Guidelines/asbs_bspc.pdfnesStatements/Guidelines/asbs_bspc.pdf

Emergency Care of the Bariatric PatientEmergency Care of the Bariatric Patient

http://s3.amazonaws.com/publicASMBS/http://s3.amazonaws.com/publicASMBS/ASMBS_Store/ASMBS_ER_Poster9-20-10.pdfASMBS_Store/ASMBS_ER_Poster9-20-10.pdf

DownloadDownload the the poster poster for your Emergency for your Emergency Department or Acute Care ClinicDepartment or Acute Care Clinic

Pre-Surgical Psychological AssessmentPre-Surgical Psychological Assessment http://s3.amazonaws.com/publicASMBS/http://s3.amazonaws.com/publicASMBS/

GuidelinesStatements/Guidelines/GuidelinesStatements/Guidelines/PsychPreSurgicalAssessment.pdfPsychPreSurgicalAssessment.pdf

Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient http://s3.amazonaws.com/publicASMBS/http://s3.amazonaws.com/publicASMBS/

GuidelinesStatements/Guidelines/aace-tos-asmbs.pdfGuidelinesStatements/Guidelines/aace-tos-asmbs.pdf

ASMBS Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient http://s3.amazonaws.com/publicASMBS/http://s3.amazonaws.com/publicASMBS/

GuidelinesStatements/Guidelines/bgs_final.pdfGuidelinesStatements/Guidelines/bgs_final.pdf

Non-Emergent Non-Emergent ConcernsConcerns

RNY Gastric Bypass and RNY Gastric Bypass and Dumping SyndromeDumping Syndrome

Common “side effect” (85%)Common “side effect” (85%) Essentially a known result of the anatomic Essentially a known result of the anatomic

changes associated with the surgerychanges associated with the surgery Can range from mild to severeCan range from mild to severe Rapid emptying of the gastric pouch of Rapid emptying of the gastric pouch of

refined sugars (HFCS) or other high refined sugars (HFCS) or other high glycemic carbohydrates or other glycemic carbohydrates or other osmotically concentrated foods, such as osmotically concentrated foods, such as dairy products and some fats such as fried dairy products and some fats such as fried foodsfoods

““Benefit” of Dumping Benefit” of Dumping SyndromeSyndrome

Negative feedbackNegative feedback

Causative foods will interfere with Causative foods will interfere with success of long-term weight losssuccess of long-term weight loss

Patient is less likely to eat the same Patient is less likely to eat the same foods againfoods again

Bad effects of DumpingBad effects of Dumping

Symptomatically uncomfortableSymptomatically uncomfortable

Confusion with other etiologiesConfusion with other etiologies

Can be difficult to manageCan be difficult to manage

May have short-term physiological May have short-term physiological consequencesconsequences

Two Types of DumpingTwo Types of Dumping

Early:Early: 30-60 minutes30-60 minutes Duration up to 60 minutesDuration up to 60 minutes Osmotic symptoms: Osmotic symptoms:

sweating, flushing, lightheadedness, sweating, flushing, lightheadedness, tachycardia, palpitations, desire to lay down, tachycardia, palpitations, desire to lay down, upper abdominal fullness, nausea, diarrhea, upper abdominal fullness, nausea, diarrhea, cramping, active, audible bowel soundscramping, active, audible bowel sounds

Caused by release of gut hormones with Caused by release of gut hormones with vasoactive effectsvasoactive effects

Two Types of DumpingTwo Types of Dumping

Late:Late: 1-3 hours after eating1-3 hours after eating

Reactive hypoglycemia symptoms:Reactive hypoglycemia symptoms: Sweating, shakiness, loss of concentration, Sweating, shakiness, loss of concentration,

hunger, fainting and passing outhunger, fainting and passing out Related to insulin surge overshooting Related to insulin surge overshooting

glucose levelsglucose levels

Diagnosis of Dumping Diagnosis of Dumping SyndromeSyndrome

History:History: Classic symptoms related to food intakeClassic symptoms related to food intake

Management of Dumping Management of Dumping SyndromeSyndrome

EarlyEarly Dietary compliance with an appropriate dietDietary compliance with an appropriate diet

LateLate Dietary compliance Dietary compliance Intake of a small amount of sugar (1/2 glass Intake of a small amount of sugar (1/2 glass

juice) 1 hour after a mealjuice) 1 hour after a meal Acarbose or Somastostatin in resistant Acarbose or Somastostatin in resistant

casescases Rule out rare causes such as insulinomaRule out rare causes such as insulinoma

Bowel Function after Bowel Function after Bariatric SurgeryBariatric Surgery

DiarrheaDiarrhea Most common with Duodenal Switch Most common with Duodenal Switch

proceduresprocedures Less common with RNY gastric bypassLess common with RNY gastric bypass Uncommon with Sleeve gastrectomy or Uncommon with Sleeve gastrectomy or

Gastric bandingGastric banding Caused by FAs, undigested foods and Caused by FAs, undigested foods and

Sorbitol (occurs naturally in fruits)Sorbitol (occurs naturally in fruits)

Management of DiarrheaManagement of Diarrhea

Dietary:Dietary: Avoidance of fatsAvoidance of fats Identify other trigger foodsIdentify other trigger foods Evaluate for previously unmasked Evaluate for previously unmasked

lactose intolerance: eliminate dairy lactose intolerance: eliminate dairy completelycompletely

Medical:Medical: Imodium or LomotilImodium or Lomotil ProbioticsProbiotics Cholestyramine to bind bile saltsCholestyramine to bind bile salts

C diff ColitisC diff Colitis

Can occur up to 3 months after Can occur up to 3 months after surgerysurgery

Severe cramping, especially watery Severe cramping, especially watery diarrhea, extremely foul flatusdiarrhea, extremely foul flatus

Treat with FlagylTreat with Flagyl Relapses commonRelapses common Follow up with probioticsFollow up with probiotics

ConstipationConstipation Common after bariatric surgeryCommon after bariatric surgery Causes:Causes:

Insufficient intake of waterInsufficient intake of water Insufficient intake of fiberInsufficient intake of fiber Diuretics (caffeine?)Diuretics (caffeine?) Nutritional supplements with Calcium and Nutritional supplements with Calcium and

IronIron NarcoticsNarcotics

Management:Management: Increased water and fiber intakeIncreased water and fiber intake Avoidance of aggravating agentsAvoidance of aggravating agents

Bowel Changes after Bowel Changes after Bariatric SurgeryBariatric Surgery

Caveat:Caveat:

Don’t assume that all bowel Don’t assume that all bowel function problems are related function problems are related to bariatric surgeryto bariatric surgery

Recent changes in a previously stable Recent changes in a previously stable patientpatient

Postoperative DysphagiaPostoperative Dysphagia

Most commonly associated with restriction Most commonly associated with restriction proceduresprocedures

Symptoms: chest pressure or tightness in the Symptoms: chest pressure or tightness in the throatthroat

May be functional:May be functional: Eating too fastEating too fast Eating too muchEating too much Not chewing well enoughNot chewing well enough Tough foodsTough foods

Breads, rice and pastasBreads, rice and pastas Overcooked steak or dry chicken breastOvercooked steak or dry chicken breast

Postoperative DysphagiaPostoperative Dysphagia

TreatmentTreatment Better eating habitsBetter eating habits

Failure to respond or severe Failure to respond or severe symptomssymptoms Band adjustment (loosening) or Band adjustment (loosening) or

endoscopic dilationendoscopic dilation

Postoperative NutritionPostoperative Nutrition

Purely restrictive proceduresPurely restrictive procedures Gastric Banding, Sleeve Gastrectomy, Gastric Banding, Sleeve Gastrectomy,

Vertical Banded GastroplastyVertical Banded Gastroplasty Daily multivitaminDaily multivitamin Monitor protein intake Monitor protein intake

1 gm protein/kg ideal body weight/day1 gm protein/kg ideal body weight/day

Postoperative NutritionPostoperative Nutrition

Primarily Restrictive with some Primarily Restrictive with some malabsorptionmalabsorption Gastric BypassGastric Bypass

Calcium, Iron and B-complex Calcium, Iron and B-complex vitamins supplemented at higher vitamins supplemented at higher than daily recommended levelsthan daily recommended levels

Prioritize protein intakePrioritize protein intake

Postoperative NutritionPostoperative Nutrition

Primarily Malabsorptive ProceduresPrimarily Malabsorptive Procedures BPD +/- DSBPD +/- DS

Calcium, IronCalcium, Iron Protein Protein Fat Soluble Vitamins (A, D, E, K)Fat Soluble Vitamins (A, D, E, K) Hydration Hydration

Deficiencies can be resistant to Deficiencies can be resistant to therapy!therapy!

Nutritional DeficienciesNutritional Deficiencies Protein:Protein:

Hair loss, Fatigue, Leg swellingHair loss, Fatigue, Leg swelling CalciumCalcium

Bone painBone pain IronIron

FatigueFatigue ZincZinc

Brittle nailsBrittle nails Vit AVit A

Decreased night visionDecreased night vision

Nutritional DeficienciesNutritional Deficiencies

Vit EVit E Poor wound healingPoor wound healing

Vit KVit K Easy bruisingEasy bruising

Vit B1 (thiamine)Vit B1 (thiamine) Numbness and tingling in hands and feetNumbness and tingling in hands and feet

Vit B12 (Methylcobalamin)Vit B12 (Methylcobalamin) fatiguefatigue

Exercise Exercise

IMPERATIVEIMPERATIVE Weight loss will not occur without itWeight loss will not occur without it 40 minutes per day, 6 days per 40 minutes per day, 6 days per

week, strenuous enough to breathe week, strenuous enough to breathe deeply but still able to conversedeeply but still able to converse

Light resistance training a benefitLight resistance training a benefit Some patients may be “exercise Some patients may be “exercise

naïve” or even “alienated”naïve” or even “alienated”

Emergent Emergent ConcernsConcerns

Emergency PresentationsEmergency Presentations

Unstable Vital Signs:Unstable Vital Signs: Fever > 102 FFever > 102 F HypotensionHypotension

Remember incidence of hypertensionRemember incidence of hypertension Tachycardia >120 bpm X 4 hoursTachycardia >120 bpm X 4 hours TachypneaTachypnea HypoxiaHypoxia Decreased urinary outputDecreased urinary output

Emergency PresentationsEmergency Presentations

BleedingBleeding Per mouth or rectum or drainagePer mouth or rectum or drainage

Abdominal pain or colic > 4 hoursAbdominal pain or colic > 4 hours Nausea Nausea ++ Emesis > 4 hours Emesis > 4 hours Emesis Emesis ++ Abdominal pain Abdominal pain

Principles of Principles of ManagementManagement

Critical Time Frames:Critical Time Frames: Diagnosis within 6 hoursDiagnosis within 6 hours To OR in 12-24 hoursTo OR in 12-24 hours

Critical WarningsCritical Warnings Alert Bariatric SurgeonAlert Bariatric Surgeon Patients typically have less physiologic reservePatients typically have less physiologic reserve Avoid blind placement NG tubeAvoid blind placement NG tube Avoid NSAIDs, ASA, Plavix, SteroidsAvoid NSAIDs, ASA, Plavix, Steroids Use PPIs routinelyUse PPIs routinely Be mindful of small volume of gastric pouchBe mindful of small volume of gastric pouch

Initial AssessmentInitial Assessment

Serial PE and VitalsSerial PE and Vitals Labs:Labs:

CBC, CMP, AmylaseCBC, CMP, Amylase Imaging:Imaging:

Chest XrayChest Xray CT of ChestCT of Chest CT of AbdomenCT of Abdomen Upper GIUpper GI

Initial Management:Initial Management:FAST HUGFAST HUG

Food: establish nutritional support earlyFood: establish nutritional support early AnalgesiaAnalgesia Sedation: if on ventilatorSedation: if on ventilator Thrombo-embolism prophylaxisThrombo-embolism prophylaxis

Mechanical and MedicalMechanical and Medical Head of Bed: elevated 30 deg Head of Bed: elevated 30 deg

(aspiration)(aspiration) Ulcer Prophylaxis: PPIsUlcer Prophylaxis: PPIs Glucose Control: <150Glucose Control: <150

BleedingBleeding

< 48 hours: staple line< 48 hours: staple line > 48 hours: marginal ulcer> 48 hours: marginal ulcer Oral: gastric pouch Oral: gastric pouch Melena or rectal blood: duodenal Melena or rectal blood: duodenal

ulcer, bypassed stomach or bowel ulcer, bypassed stomach or bowel source source

EGD: consider GA in OR EGD: consider GA in OR Increased risk of perforation with Increased risk of perforation with

interventionintervention

Leaks and SepsisLeaks and Sepsis

Presentation: unstable VSs within 72 Presentation: unstable VSs within 72 hours of bariatric surgeryhours of bariatric surgery

Persistent or progressive Persistent or progressive tachycardia is most sensitivetachycardia is most sensitive

Similar presentation to PESimilar presentation to PE Imaging can be negativeImaging can be negative

ObstructionObstruction

Presentation:Presentation: Abdominal pain > 4 hours associated with vomitingAbdominal pain > 4 hours associated with vomiting

Do Do NOTNOT place NG tube place NG tube Diagnostics:Diagnostics:

CT abdo with contrast or UGICT abdo with contrast or UGI Increased risk for aspiration due to small Increased risk for aspiration due to small

volume of stomachvolume of stomach Consider EGD prior to anesthesia to R/O GOO Consider EGD prior to anesthesia to R/O GOO

and empty contrast material to decrease risk and empty contrast material to decrease risk of aspirationof aspiration

ObstructionObstruction

Special ConcernsSpecial Concerns:: Acute bleed causing obstruction Acute bleed causing obstruction

secondary to clotssecondary to clots Internal hernias after gastric bypassInternal hernias after gastric bypass Evaluation/imaging / PE may be negativeEvaluation/imaging / PE may be negative

Dilated distal stomach or contrast in remnantDilated distal stomach or contrast in remnant High risk for closed loop obstruction High risk for closed loop obstruction Bowel ischemic necrosis within 6 hoursBowel ischemic necrosis within 6 hours Immediate surgical explorationImmediate surgical exploration

Internal herniasInternal hernias

A. Transverse A. Transverse MesocolonMesocolon

B. Petersen Hernia:B. Petersen Hernia: Beneath Roux limbBeneath Roux limb

C. Mesentery C. Mesentery defect created by defect created by jejunojejonostomyjejunojejonostomy

Pulmonary EmbolismPulmonary Embolism

Extremely high risk patientsExtremely high risk patients Unstable vitals associated with chest Unstable vitals associated with chest

pain and tachypneapain and tachypnea Evaluation with Chest CTEvaluation with Chest CT Can mimic acute intra-abdominal Can mimic acute intra-abdominal

complicationcomplication

Vomiting Vomiting ++ Abdominal Abdominal PainPain

Gastric BandingGastric Banding AXR: assess orientation of bandAXR: assess orientation of band Deflate bandDeflate band

Huber needleHuber needle Similar to a PortacathSimilar to a Portacath

ReassessReassess Does not usually require surgeryDoes not usually require surgery

Adjustable Gastric BandAdjustable Gastric Band

Normal Band Normal Band orientationorientation 2:00-8:002:00-8:00

Normal orientation Normal orientation but too tightbut too tight

Adjustable Gastric Band Adjustable Gastric Band SlipsSlips

Anterior Slip:Anterior Slip: Band rotated Band rotated

counterclockwisecounterclockwise

Posterior Slip:Posterior Slip: Band rotated Band rotated

clockwiseclockwise Note: enlarged Note: enlarged

pouch flopping over pouch flopping over slipslip

Vomiting Vomiting ++ Abdominal Abdominal PainPain

Unstable:Unstable: Immediate surgical explorationImmediate surgical exploration

Stable:Stable: Evaluate per obstructionEvaluate per obstruction Barium swallow most usefulBarium swallow most useful

Abdominal Compartment Abdominal Compartment SyndromeSyndrome

Respiratory failureRespiratory failure Renal failureRenal failure Other end organ failureOther end organ failure Elevated bladder pressure (> 25 Elevated bladder pressure (> 25

mmHG)mmHG)

Emergent abdominal decompressionEmergent abdominal decompression

“George, how often do you have a leak?

“Never had one” “In how many cases?” “Oh, I’ve never done one . . . . .”

Surgery for Obesity and Related Diseases 7 (2011) 668

SummarySummary Complications are unavoidable but Complications are unavoidable but

disasters are often avoidabledisasters are often avoidable Be familiar with the perioperative Be familiar with the perioperative

concerns that face the bariatric patientconcerns that face the bariatric patient Be aware of the signs of complications Be aware of the signs of complications

after bariatric surgeryafter bariatric surgery Plan for initial management and Plan for initial management and

stabilization of the patient facing stabilization of the patient facing postoperative complicationspostoperative complications

Early involvement of a Bariatric Surgeon Early involvement of a Bariatric Surgeon Work with a certified Center of ExcellenceWork with a certified Center of Excellence

ASMBS or ACSASMBS or ACS