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IFSO Bariatric Physician's Role

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					               IFSO
    Bariatric Physician’s Role
  Pre operative & Postoperative

              SASHA STILES MD
        NYU LANGONE MEDICAL CENTER
PROGRAM FOR MEDICAL & SURGICAL WEIGHT MANAGEMENT
                  DISCLOSURE

 I am employed by NYU Surgical Associates
  practicing with Drs Ren, Fielding, Kurian and
  Schwack
 Rosalie Tanaka is my graphic artist and she has
  nothing to disclose and receives no financial
  remuneration for her work (though she should!)
 Other than that I have no disclosures
      I. PRE OPERATIVE CARE OUTLINE


 Recommended Best Practices for Bariatric Physician:
             ASMBS COMPENDIUM – review & fyi
   Controversies: Preoperative Weight Loss
   Controverseis: To walk or not to walk & why
   Controversies: Insurance requirements
   Controversies: PCP readiness to refer for surgery

 My Curbside Consult….
Bariatric Physician Best Practices:
       Preoperative Primer
      ASMBS Compendium
            ASMBS COMPENDIUM
           SASHA STILES MD, MPH
             MEDICAL DIRECTOR
    TUFTS OBESITY CONSULTATION CENTER
           The Bariatrician’s Role:

1. Assess & improve medical issues
2. Supervise psych and mobility assessments
   & interventions by qualified team members
3. Supervise and punctuate the education
   provided by team members which is necessary
   for the successful bariatric surgery patient pre
   & post op
4. Send an educated & metabolically more stable
   patient to the surgeon for potential surgical
   intervention
5. Create a safe and satisfying environment to
   keep the patient involved post op as well
            Compendium Outline


1.   Introduction: Severe Obesity Instruction for
      PCP & Patient : what is different
2.   Review of Systems: including pertinent
     negatives
3.   Social, Family & Weight Loss History
4.   Review of Psych Recommendations
5.   Physical Exam of Obesity
6.   Significant Labs & Special Tests
7.   TO DO List
            I. Obesity-Specific Skill Set


1. BMI = weight/height squared

2. Ideal Body Weight: Metropolitan Life Table
      adult female: 5 ’tall = 119 lb.+ 3lb/inch
      adult male: 5’3 tall = 135 lb + 3 lb/inch

3. Excess Weight = initial weight – ideal weight

4. %EWL = preoperative wt – current wt
         __________________ x 100
            preoperative wt – ideal weight
The Metabolic Syndrome factors to evaluate

Risk factor         Defining level

1. Abdominal Obesity = Waist Circumference
      Men >102 cm (>40 in)
      Women >88 cm (>35 in)
2. Triglycerides ≥150 mg/dL
3. HDL cholesterol
      Men <40 mg/dL
      Women <50 mg/dL
4. Blood Pressure    ≥130 / ≥85 mm Hg
5. Fasting Glucose ≥100 mg/dL
                     Medical Complications of Obesity1

            Pulmonary Disease
              Abnormal Function                                                        Idiopathic Intracranial
              Obstructive Sleep Apnea                                                  Hypertension
                                                                                          Stroke
              Hypoventilation Syndrome
                                                                                                Cataracts
             Nonalcoholic Fatty
             Liver Disease                                                                        Coronary Heart
                Steatosis                                                                         Disease
                Steatohepatitis                                                                       Diabetes
                Cirrhosis                                                                             Dyslipidemia
                                                                                                      Hypertension
       Gall Bladder Disease                                                                           Severe Pancreatitis
    Gynecologic Abnormalities                                                             Cancer
       Abnormal Menses                                                                        Breast, Uterus, Cervix,
       Infertility                                                                            Colon, Esophagus, Pancreas,
       Polycystic Ovarian Syndrome                                                            Kidney, Prostate
                    Osteoarthritis                                                         Phlebitis
                                                                                               Venous Stasis
                                     Skin
                                          Gout
1. Obesity OnLine slide presentation. Accessed May 17, 2007. Accessible as slide #5 at http://www.obesityonline.org/slides/slide01.cfm?tk=33.
     Kral Severity Index II: Psychosocial
Socioeconomic = 2.0       Race/Ethnicity/Culture
  educ <HS grad=1.5         Black =1
  public insurance=0.5 Hispanic = 1
  unmarried = 0.5       Significant co-depend =2
  unemployed = 0.5      Beliefs
Psychaitric = 7.0        unreasonable expect=1
 hosp admis = 2.0               denial of disease = 0.5
 manifest psychopath = 2 Preoperative behaviors
 testing abnormality=1/0 Poor appt keeping = 0.5
 childhood abuse = 2.0       Still smoking = 0.5
Addiction: etoh = 0.5        prior ob. Surg = 1.5
            drugs = 1.5                1996!!
DeMaria: Mortality Risk Score 2007
N= 2075 Gastric Bypass 1995-2004
independent variables correlated with mortality:
1. Male
2. HTN
3. BMI>50
4. Age>45
5. Novel Pulmonary embolism risk: ( previous
    thrombosis, pulmonary embolus, inferior vena cava
    filter, right heart failure, obesity hypoventilation )

  DeMaria E, SOARD 3 (2007) 134-40.
                 Mortality due to #
                  comorbidities


      Comorb       deaths   N         mort rate%

Class A:   0-1     3        957          0.31%

Class B:   2-3     19       999          1.90%

Class C:   4-5      9       119          7.56
    What I tell people about why they need to
                   lose weight

1. Genetic “Central” Selection
2. Why I measure Waist Circumference:

3. Lowering WC & Surgical Technique:
     improved exposure
     thick abd wall
     difficulty moving surgical instruments
     viscera obscured by fat, enlarged liver
     pneumoperitoneum less difficult to achieve
           From cave men (and ladies)
Cave men – central
obesity and ability to
store fat




                                        One of the earliest
                                        known depictions of
                                        the human form,
                                        The Venus of
                                        Willendorf
                                        statuette dates to
                                        between 22,000
                                        B.C.E. and 21,000
                                        B.C.E.
                To the remote
Extinction???
       Modest ( 10% ) weight loss
             can achieve:


Better DM, Asthma and HTN control
Improved sleep apnea ( 50% deceased apnea)
Better general cardiac functioning
Improved heart rate variability
Less shortness of breath
Better Exercise capacity & less pain
         The Bariatric Consultation
HT: __ Wt: __ BMI: ___ WC:__ NC:__
Pre-op goal wt:__ Age:__
Allergies:
Medication List:
EKG of Obesity: may be normal
 flat infer T __/ST depr__/ QTc>400__/
 low QRS__/ L axis dev__/
 false + MI female__
CXR: __ the lesion you do not want to miss
               Template,ROS

MEDICAL COMORBIDITIES: pertinent negatives
1. CARDIAC:
 a. dvt / pulm embolism __
     lower extremity doppler__
     spiral ct __
     greenfield filter __
     coumadin when & why __
 b. MI __ / angina__/undiagnosed chest pain__
 c. HTN __
 d. CHF __
 e. Arrythmia __
 f. Other ( murmurs / surgeries )__
                Cardiac Issues
FLUID STATUS:
severe obesity is a risk factor for CAD
    independent of HTN, DM
severe obesity = increased blood volume, preload
    & cardiac output: 30 ml blood volume/ Kg
    adipose tissue
Increased catecholamines, mineral corticoids,
    renin and aldosterone = increased afterload
               Cardiac Studies

STRESS STEST can clarify risk and who might need
    a cath prior to surgery.
  Suggested criteria for study:
1. Atypical chest pain
2. Known CAD or history of MI: small dense LDL?
3. Age >55 ?
4. So sedentary that immobility may mask
    ischemia
5. Diabetes >10 years
    plaques with 40% occlusion rupture. use statins
      Which Cardiac Study is best?
1. In your institution which technician and
    which imaging machine is best? Cost?
2. Stress Imaging:
  a. Dobutamine echo
  b. Adenosine/Persantine Nuclear - may be
    problematic if SOB
 c. Trans Esophogeal Echo - best for RHF
 3. Consider Pulm HTN - plain echo
 4. EKG - Magnesium & Potassium:
exacerbated by dehydration and sudden weight
    loss
             Template, ROS cont
2.   DERM
     cellulitis
     lymphedema
     psoriasis
     easy bruising ( cush)
     acanthosis nigrans
     other
            Template ROS cont
3. ENDOCRINE
1. DM:
   a. Patient has been diabetic for ___ yrs
   b. Daily accuchecks ___
   c. Last HA1c__ ( by 6.0 = 80% b cell lost )
   d. Meds schedule
2. Hypothyroid
3. Hyper parathyroidism of obesity
4. Pregnancy
5. PCOS
                 Template ROS cont
IV.   GI
 gall bladder issues
 ulcerative colitis/crohnes
 ibs moderate to severe
 chronic nausea and vomiting
 gerd
 hiatal hernia
 evidence of extent of hiatal hernia- for Band
 endoscopy
 UGI-SBFT
                Template ROS cont


GI continued:
 ulcer history
 hepatitis
      hepatitis studies including ultrasound/bx?
 diverticulitis
 NAFL
 abdominal ultrasound
 abdominal surgeries for hernia
             for bowel obstruction
             exploratory lap
             cancer
                 Template GI issues
1.   Stool analysis for H.Pylori antigen ?
2.   Endoscopy upper/lower: for past ulcer, anemia
     of unknown etiology, or history of colon disease
3.   Steatohepatitis: when to order ultrasound for
     liver size, cirrhosis issues. Include Ferritin and
     LFTS in lab panel
4.   What cholelithiasis to treat and how.
              Template ROS cont

5.  HEME/VASCULAR
 anemia__/ iron deficiency __/ thal trait __
 hx blood transfusions
 Jehovahs Witnesses
 clotting disorders
 venous insufficiency
 hyperlipedemia: LipoScience Lipid Panel: NMR
    Triglyc & HDL improve with weight loss. LDL
    may need statins
          Hematological controversies

Thromboembolic workup considerations
 a. anticoagulate if AF, past cva?, cardiac stents?
 b. Greenfield filter for prior DVT/PE or
 significant venous stasis disease
 c. Clotting Studies:
     antithrombin III, anticardiolupin AB,
    ANA, fibrinogen, PT/PTT, Leiden V,
    Homocysteine, Protein C/S,
    gene mutation 20210
              Template ROS cont

6.  FEMALE: G__P__
 PCOS/ hirsute, oligomen & insulin resistance
 peri/menopausal
 regular menses vs heavy or prolonged menses
 pcos: hirsute & 9/12 menses irreg
 hysterectomy__/ tubal ligation__ /
 other birth control
              Template ROS cont

7.  MUSULOSKELATAL:
 back pain
 knee pain
 foot pain
 ankle pain
 other severe arthridities
 gout
 assistive devises
                  Pulmonary

WHY PATIENTS NEVER GET TO SURGERY:
Delays, frustration and hopeless due to:

1. Can’t stop smoking
2. Super obese
3. Sleep Apnea work up and treatment:
 how I compel them to stay the course
              Template ROS cont

8.   PULMONARY:

      O2 sat at rest
     Peak Flow
     asthma/severity
     sleep apnea____/ RDI___ / on cPAP___
              % desat in 80’s or lower
     pulmonary function tests
               Pulmonary Issues

1. PFTS Restrictive: increased pulm blood
   volume, increased chest wall mass,
   decreased lung volume
2. Abnormal diaphragm position
3. Obstructive upper airway resistance
4. Obstructive Sleep Apnea
5. Co2 retention, decreased O2
6. Increased work of breathing
7. Pulmonary HTN, Right Heart Failure
8. Sleep related dysrhythmias
9. Polycythemia
              Pulmonary Issues
POLYCYTHEMIA & clot risk:
 increased blood viscosity
 decreased concentration of Anti-thrombin III
 Increased concentration Fibrinogen and PAI 1
   produced by adipose tissue
 Sedentary Life style, venous stasis & pulmonary
  HTN augments risk
              Template: ROS cont.

9. NEURO:
 Sciatica ____ / Neuropathy____
 Disc disease & neuro compromise
 Seizures __ / Migraines __
 Fibromyalgia ___/ Multiple Sclerosis __
 CVA _______ TIA ___
   carotid doppler__/ carotid bubble __
   head scan
 Pseudo tumor cerebri
 Vertigo, Unsteady balance, Unsteady gait
 *Any known other neuro studies & why
             Template ROS cont

10. URO/RENAL
 frequent pyelo
 kidney stones/ #/ stone &/or urine analysis
 renal insufficiency/ failure
 incontinence
 prostatitis
 oxalurea *** low calcium intake?
11. OTHER MEDICAL/CANCER HISTORY
                Template cont


PSYCH HX &/OR PSYCH Consult Review
 include eating disorder evaluation
 include consideration of eating disorder rx
   consisting of in-house mindfulness/DBT
   pre-op
 include assessment of stability of DSM IV dx
              Template cont
SOCIAL HISTORY

employment
disabled date and details
current & past etoh
smoking current & past
who lives with you? Single___ / Married __
   children,extended family ___
                  Template cont

EXERCISE: CV Fitness & Joint Functionality
 Current Exercise: length>strength to preserve joints
 Exercise Limitations
 Mets: to asses CV: ( amount of energy expended where
  1 met = energy expended on sitting quietly)
            Light <3 mets, <3-5 kcal/min
            Moderate: 4-6 mets, 3.5-7 kcal/min.
                   example: 2 flights stairs
             Vigorous: >6 mets, >7 kcal/min
FAMILY HISTORY:
dm__/ HTN__/ MI___/ severe obesity ___other___
AGE GAINED WEIGHT & why: childhood, preg, injury
                   Template cont


SURGICAL HISTORY:
 Abdominal Surgical History:
  gb__/ appy__/ abd hernia__ / wt loss __
  any other abdominal surgery
 GYN surgery
   tl__/ cs __/ hysterectomy__ / other __
 Other Significant Surgical History:
     dd catastrophizers & minimizers
Significant HOSPITALIZATIONS:
  you would be surprised what you pick up!
      the chest pain you missed on ROS!
             Template cont

SUGGESTED ADULT PREVENTIVE SCREENS
 cholesterol screen
 diabetic: retinal screen and HA1c
 flex sig/colonoscopy or FOB/FIT
 cervical screen
 mammography
 tetanus, influenza and pneumovac

EPWORTH SLEEP SCALE
STANFORD SLEEP SCALE
STANDARD SLEEP QUESTIONS
               Template cont

PHYSICAL EXAM
 HEENT: nc/at. Eoms full/perrl,anicteric
 orophar lesions. Orophar collapse(SAS)
 moon facies/rounding & plethora (cush)
 smooth tongue ( B deficiencies )
 clubbing ( hypoxia )
 puffy nonpitting lids ( low thyroid )
 exopthalmus ( high thyroid )
         Template Physical Exam cont

SKIN: acan ( PCOS, other endocrinopathies )
 hirsuit ( cushings and pcos )
 jaundice
 coarse dry hair thinning ( low thyroid )
 skin thinning (cushings )
 easy bruising ( cushings, micronutrient defic,
  medications, clotting issues)
NECK: supple__/ masses__/ JVP est___
  CVP est, dorsal hand vein ___
  Dorsocervical hump ( cushings )
         Template Physical Exam cont

CHEST: clear__/ wheezes, rales rhonchi__/
         supraclavicular fat pads
COR: RR__/ no murmur__/ split S2 1st intercost
                               space ( cor pulm )
    SOB as getting up and down from exam table
ABD: central obesity/ assess firmness
 scars __/ hernia ___ bilobed pannus ___
EXTREMITIES: varicosities/ nonhealing ulcers /
  taught/ pitting edema/ lymphedema
         Template Physical Exam cont

NEURO/ MUSCULAR:
 CN ii-xii
 gait __/ balance ___
 tremor: resting (park)/
          intention ( cerebellar, MS )
          static( hyperthy or B9 essential)
Proximal muscle weakness ( cushings )
Difficulty sit to stand:
            VITA. Pre op / Post op Bypass LAB
Bari review      2 weeks pre          6 -12 months   Annual

albumin          nicotine             albumin        albumin
CBC              High sensitiv Preg   cbc            cbc
Creat / GFR      cbc                  Creatinine     Creatinine
ELECTROLYTES     Creatinine           Electrolytes   Electrolytes
THIAMINE         Electrolytes         thiamin        ferritin
LIPIDS           FBS                  Lipid          FBS, +/- A1c
PTH                                   PTH            Cu
FERRITIN                              ferritin       Lipid panel
VIT A, D25OH                          Vit A, D25oh   Liver Panel
B 12, B1                              Vit B12, B1    PTH
URIC & MG                             Uric, Mg       Thiamin
LIVER PANEL                           FBS & A1C      Uric Acid, Mg
FBS/ HA1C                             Liver panel    Vit A, D25oh,A
Vitamin A                                            Vit B12
          Template Laboratory Review

Malnutrition Preop? or Inflammatory
 Markers
THIAMINE: Preop may be very low nl
   first sign low thiamine is nausea & vomiting
   later neuropathy, balance & cn issues
PTH if high before surgery evaluate
Vitamin D low preop
ANEMIA pre-op: PLEASE get Ferritin
Consider CRP
        Template Laboratory Eval

KIDNEY STONE EVAL: role of
 dehydration plus
 a. low calcium absorption & calcium
      oxalate stones
  b. high calcium absorption and kidney
      stones
ORDER 24 hr urinary stone analysis and
 compare with blood analysis: uric ac,
 calc, oxalate, other
Role of PTH
                 Template cont


ASSESSMENT:
PLAN:
 PCP TASKS
 CONSULTATIONS SENT
  Specialty
  Imaging
  Sleep study
  Pulmonary Function Tests
             Template, Plan cont


MULTIDISCIPLINARY TEAM REVIEWS:
 NUTRITIONAL Consultation ordered
 EXERCISE Evaluation & Treatment Ordered
 PSYCH Evaluation Ordered
 Individualized Bariatrician TO DO LIST
              Example To Do List
1.  Wt goal
2.  Exercise goal
3.  Nutrition appt individual/class/fitday.com
4.  Stop smoking
5.  Psych eval
6.  Ekg, Cxr and Lab
7.  Behavioral/education class set
8.  Specialty consultations: cardiac, other
9.  Specialty imaging: cardiac other
10. Sleep study and C pap titration
11. Recheck with YOU as frequently as needed for
    insurance or your centers weight loss requirement
12. Send to surgeon as requested by your surgeon
                 And Finally


Initial visit = teaching & information
              gathering
Subsequent visits = negotiation!!!
 1. Assess Labs & Studies
 2. Assess Med changes
 3. Nutrition & Vitamins
 4. Assess CV Fitness & Mobility
 5. Acknowledge Psychological Stability
 FYI weight loss is the END result after time,
     education & improved health status
                           REFERENCE LIST

 1. Dietel M, Gawdat K. Reporting Weight Loss 2007. Obes Surg 2007;17:
 565- 568.
 2. Wilson P, D’Aostino R. Overweight and obesity as determinants of
    cardiovascular risk: the Framingham experience. Arch Int Med 2002;162:1867-72.
   3. Kral JG. Side effects, complications and problems in anti-obesity surgery:
    introduction of the obesity severity index. Progress Ob Res Ch 92.1996;655-661.
   4. DeMaria EJ, Portenier D. Obesity surgery mortality risk score: proposal for a
    clinically useful score to predict mortality risk in patients undergoing gastric bypass.
    SOARD 2007; 3:134-140.
   5. Leslie D, Kellog T. Bariatric surgery primer for the internist: keys to the surgical
    consultation. Med Clin of NA 2007;91.
   6. Kuruba R, Koche LS. Preoperative Assessment and perioperative care of patients
    undergoing bariatric surgery. Med Clin NA 2007;91:339-335.
   7. Torquati A, Wright K. Effects of gastric bypass operation on Framingham and
    actual risk of cardiovascular events in class II-III obesity. Am Coll Surg 2007; 204-
    776-771.
   8. Flood C, Fleisher L. Preparation of the cardiac patient for noncardiac surgery.
    Am Fam Phys 2007; 75:656-664.
 9. Fraley MA, Birchem N. Obesity and the electrocardiogram. Obesity
    Reviews 2005; 6;275-281.
   10. Fisler J. Cardiac effects of starvation and semistarvation diets: safety
    and mechanisms of action 1992. Am J Nut;99:230S-234S.
   11. Alpert M. Management of obesity cardiomyopathy. AM J Med Sci
    2001;321:237-241.
   12. Alpert M, Fraley MA. Management of obesity cardiomyopathy. Expert
    Rev Cardivasc Ther 2005;3:225-130.
   13. Goldman L. Cardiac risks and complications of noncardiac surgery. An
    Int Med 1983:98:504-513.
   14. Grayburn PA, Hillis LD. Cardiac Events in Patients Undergoing
    Noncardiac Surgery: shifting the paradigm from noninvasive risk
    stratification to therapy. Ann Int Med 2003;138:506-512.
   15. Gallagher MJ, Franklin BA.Comparative impact of morbid obesity vs
    heart failure on cardirespiratory fitness. Chest 2005;127.
   16. McCullough PA, Gallagher MJ. Cardiorespiratory fitness and short-term
    complications after Bariatric surgery 2006. Chest;130.
 17. Porier P, Giles TD. AHA scientific statement:
  obesity and cardiovascular disease:
  pathophysiology, evaluation , and effect of weight
  loss. Circulation 2006;113:898-918.
 18. Porier P, Hernande,TL. Impact of diet-induced
  weight loss on the cardiac autonomic nervous system
  in severe obesity. Ob Res 2003;11:1040-1047.
   Controversy #1: PCP Referral Practices

North Carolina study mailer to PCPS:
1. 35% of PCPs felt unprepared to provide long term post
   operative care
2. 45% of PCPs felt competent in addressing complications of
   bariatric surgery
3. Referring providers were younger and were more familiar
   with NIH guidelines
4. 49% of Referring providers had attended CME in post op
   care.
CONCLUSION: Surgery Centers to provide educational
   resources

 Balduf,L and Farrell T, Attitudes, Beliefs & Referral Patterns of PCPs to Bariatric
 Surgeons, Jsurg Res 144,49-58, 2008
           Controversy #2:
Effects of Obesity on the Energetics
   and Biomechanics of Walking




               Courtesy of Ray Browning, PhD
                Center for Human Nutrition
               University of Colorado Denver
Obese Adults have Heavier Legs



                       Obese    Normal   Obese   Normal
                       Female   Weight   Male    Weight
                                Female            Male
             Thigh
                       13.5      7.9     13.7     9.7
             Mass
             (kg)       *
             Thigh
             Fat (%)
                       55.4     43.3     41.4    24.5
                        *                 *
         Sagittal Plane Knee Joint Loads


 Mechanism
    GRF causes knee torque
    Knee muscles produce counter
     torque
    Muscle forces and GRF act to
     compress joint
 Sagittal Plane Joint Torque
    Torque produced by muscle
    Proxy measure of joint load
        Frontal Plane Knee Joint Loads


 Mechanism
    GRF causes knee
     adduction torque
    Shifts joint load medially
 External knee adduction
 torque
    Proxy for distribution of
     load across tibia
    Greater in adults with
     knee OA (Andriacchi, 1994)
As expressed sometimes as bowlegs and
         large thighs: Vargas
How long / fast is your gait?

Gait Cycle & Ground Reaction Force
                   Biomechanics
1. Greater ground forces – greater sagittal
  plane knee joint torques
2. Greater peak external knee adduction
  torque - greater load wear and tear on
  medial compartment of knee
3. Increased Forces related to step width
 Risk of musculoskeletal injury partly due to
  high forces and loading rates: walking
  slower may mitigate those risks
 Walking at 1.0 vs. 1.5 m/s
  Peak A-P forces  70%
  Peak sagittal plane knee joint torque  43%
  Peak external knee adduction torque  55%
           Something to think about



 Each one pound of weight loss results in a
 Four fold reduction in the load exerted on the knee
 / step
                   Translation

 The faster the pace, the heavier the steps =
  exponentially more ground force
 These ground forces create shock waves
  throughout the lower extremities and spine
  causing wear and tear of joint surfaces
 Abnormal thigh girth, sometimes expressed as Q
  angles or with bowleggedness causes uneven
  wear and tear of these same surfaces
 Browning found that by walking slower these
  forces decreased, approaching forces of the
  nonobese
Prescribe Walking to Treat Obesity
 How much energy is required for obese adults
 to walk at a specified speed?
     obese adults can walk = 3MPH

 Increased risk of musculoskeletal injury?
  Yes,due to joint loads.
  Risk reduced by walking slower
 Can energy expenditure goals be achieved while
 reducing risk of injury?
  Possibleby walking slower for longer distance
  BUT Slower not moderate intensity = less
   cardiovascular benefit
        Something else to think about


In patients applying for weight loss surgery:
one study showed that physical activity reported by
  patient logs was only 3% of their daily activity as
  reported by accelerometer.
      Sample Exercise Prescription
 Energy surplus ~100 kcal/day
 To prevent weight gain
   Obese adult: 15 min @ 3 MPH

   Obese adult: 1 mile @ 2 MPH



      (Lose 1 pound = 3800 calories)
      Strenuous exercise 10 calories/min
Finally a simple exercise prescription

 Thigh girth
 CV limitations
 CV exercise protocol safety
 Simple Strength Training: low wts & high reps
 Biomechanical Considerations
 What exercise is accessible, enjoyable and does not
 hurt!!!
          Pool walking
          Barco Bikes
          Chair running
  Controversy #3: Pre Operative Weight Loss??

 A modest weight loss can improve:
 Glucose control
 Blood pressure
 Sleep apnea
 Asthma
 Proinflammatory and prothrombotic states
 FRC and lung volumes
 Decreases blood volume and improves left
 Ventricular function
 Systemic and pulmonary hemodynamics
  Pre Operative Weight Loss & Visceral Fat

Pre-operative weight loss shrinks both
 Visceral > subcutaneous fat - first 8 weeks
Male, 41 yrs:
 Weight Loss = 20.0 kg
 SAT Loss = 14.5 L (44%)
 VAT Loss = 5.2 L (59%)
      (SAT = subcutaneous adipose tissue)
      (VAT = visceral adipose tissue)
            Preoperative weight loss and OSA

 Pre-operative weight loss improves OSA
Loss of 10% of body weight reduces number
    0f apneas by 50%
Reduces airway collapsibility and improves
FRC
Reduces mucosal edema
Improves responsiveness to hypercapnia and
   Hypoxemia
Improves baseline hypoxemia
   Is Pre-Operative Weight Loss Beneficial?
   Loube et al, J Am Diet Assoc 1997
   Adams and Murphy, Br J Anaesth 2000
   Hudgel, Chest 1996
    Preoperative weight loss and Inflammation

 Pre-operative weight loss decreases inflammation


Weight loss in the range of 10%
Reduces markers of inflammation
Improves pro-coagulant indices
Improves endothelial function
   Is Pre-Operative Weight Loss Beneficial?
   Festa et al, Int J Obes 2001
   Rissanen et al, Int J Obes 2001
   Ridker et al, JAMA 2001
        Pre operative weight loss and diabetes

 Pre-operative weight loss improves diabetes
 blood sugar control
 • 10 subjects with DM 2
 • Weight 101(78-161) kg
 • VLCD over 3 months, DM medications stopped
 • Average loss of 14 kg
 • Decrease in fasting glucose 15%
 • Decrease in HBA1c from 11 to 10% (NS)
   Is Pre-Operative Weight Loss Beneficial?
   Uusitupa et al, Am J Clin Nutr 1990
   SUMMARY: Pre operative Weight Loss?

 Pre-operative weight loss is feasible
   May decrease both intraabdominal fat and hepatic
   Steatosis and improve the patient’s physiologic
      condition
   Only 5-10% weight loss is necessary
   Improved the technical aspects of the surgery
   Improve patient’s health should decrease
            complications
Curbside Consult: Pre op
         OUTLINE POSTOERATIVE

 Recommended Best Practices: Band, Bypass
 Controversy: PCP Involvement
 Controversy: Low Glycemic for everyone?
 Controversy: Band Management: Negotiation
 Controversy: Weight Regain
 Controversy: Circadian Rhythm
 Controversy: Low Glycemic for Everyone?
 Controversy: The Baked Potato
 My Curbside Consult: LISTEN
        Gastric Bypass
      EARLY Post Op Care

A. GASTRIC BYPASS Surgery Center
  Visits surgeon vs. bariatrician
  Nutrition
  Post op groups – labs
B. Gastric Bypass PCP tasks
C. Complications
       BYPASS: 3 Pouch Theory
          Kathy Reto Phd Psych




 Poster child


 Irritable pouch


 Socrates
     BYPASS: Vitamin Supplementation

1.   Multivitamins and mineral Supplement:
     >100%
2.   Vit. B1; 50 mg qd
3.   Vit. B12: SL or nasal Vit. B12 1000 mcg 2-4
     times/week
4.   Iron: 15-20 mg/day – give separately not with
     Ca usu at bedtime
5.   Calcium: Preferably Calcium Citrate 1500 -
     1700 mg/day in divided doses not to exceed
     2500mg/day between food & supplement):
     pills, liquids or chews available
6.   Vit. D: 2000- 5000 unit/day including the
     multivitamin and mineral supplement Vit. D
     50,000/week?
7.   Beta-Carotene 25000 units once/week.
           Bypass & PCP Evaluation
Initial Post op Visit day 3-7day - why?
 General nutrition - 3 pouches
 Dehydration & diuretics = hold most diuretics
 Constipation – common. Fluids, otcs
 Diabetes – lower meds alot
 HTN – lower meds
 Gout – allopurinol preop - dehydration
 Rectal Bleeding – nl from GI intraluminal surgery
 Nausea and Vomiting – eat too fast, not chewing
                 Early Complications

 Nausea and vomiting
 Diarrhea
 Constipation
 Hypoglycemia
 Leaks
 Rhabdomyolysis
 Compartment syndrome
 Internal Hernias/SBOs
            Bypass: N/V vs Dumping
 DUMPING with bypass only: 50% only
   sugar load quickly metabolized = via >insulin.
 Causes transient hypoglycemia = weak, lay down,
 feel horrible, sweats, NOT usu diarrhea or vomiting
Alcohol use similar - legally drunk on far less
Vs nausea and vomiting of eating /drink too fast
Vs nausea and vomiting of low thiamine
Vs nausea or vomiting if irritable pouch
Vs dehydration- need 64 oz water a day = sip
Vs stomach too empty
Vs gastrojejunal stricture
Vs wound infection - non laparoscopic diabetic ooc
                 Bypass Diarrhea

 Cdiff infection post hospital
 New lactose intolerance – bypass
 IBS related : 1/3 rule - bypass
 Dietary fat related sometimes


 Note later diarrhea - lifestyle OR something else -
 need colonoscopy just like everyone else _ colitis,
 non bariatric infection.
                    Bypass
             Anastamotic Leak 0-2 dy

1. Incidence 0.5-3%
2. Signs: tachycardia>120, increase O2
     requirements,Sao2<92%,RR>24
3. Left shoulder pain, isolated left pleural effusion
4. Increasing abdominal pain
5. Impending doom
6. RX: UGI false negatives, Ct -size issue
7. PROCEDE TO SURGERY!!!
                   Enteric Leaks

 Gastro jejunostomy
 Gastric pouch staple line
 Gastric remnant staple line
 Jejuno jejunostomy
 Missed perforation of blind optical instrument
 insertion
    + C. PULMONARY COMPLICATIONS
   Elevated diaphragm,
   increase ventilatory pressures
   Decrease compliance
   Decrease TLV,FRC.RV

 + D. CHRONIC INFLAMMATORY STATE
-Increase IL6 & TNF alpha
-Decrease card compliance & Pulm Reserve
-Decrease Abdominal Wall Compliance
 all lead to: ACUTE COMPARTMENT
             SYNDROME
             Compartment Syndrome:

 Increase CO, decrease Vent return
 Increase afterload, decrease vent compliance
 Increase intrathoracic pressure & Diaph elev
 Increase DVT, decrease L.E. outflow
              Rhabdomyolysis
 Increased with increased OR time, Increased BMI
    and DM
   Increased with >70yrs, CPK>1600,sepsis
   Tea colored urine, fever & confusion, pain,
    swelling, bruising and weakness
   RX: pain, Hgb dipstich +=myoglobin, CPK>5000
    peaks up to 7 days later
   RX: Diurese - mobilized muscle ICF
        Alkalinization - soluble myoglobin
        Hemofiltration
               Renal complications

 Oliguria < 30 ml.dl
 Decrease renal arterial flow
 Increase sodium and water retention
     Long term nutritional complications

 Diabetic
 Hypoglycemia
 Neuropathies - esp B vitamin related
 Anemia
 Protein Calorie Malnutrition
 Folate - Neural Tube Defects
 Calcium - D
Bypass Hypoglycemia: How did we get from
      dumping to Nesidioblastosis ?

 Sympathoadrenal        Neuroglycopenia - 26%
 Diaphoresis            Fatigue, Confusion
 Tremor                 Syncope, Seizures
 Increased heart rate   Visual disturbances
 Anxiety                Speech difficulties

   Patient has hypoglycemic symptoms
   Do complete dietary evaluation
   All patients get glucometer
            Evaluation Hypoglycemia
Syncope                                      MIXED
               SYMP ADR     NEURO GLY
  or
 SYNCOPE         Sweat        Fatigue
Seizures
  SEIZURE        Flush       Confusion
                              Visual          MIXED
                Anxiety
                Tremor        speech
                 HR up




                                    Not
  Resolve                         Resolved
                          Resolve            Resolve
   With                    With    On diet
                                              With
   Diet       Not          Diet               Diet       Not
            Resolved
             On diet                                   Resolved
                                                        On diet
DURING HYPOGLYCEMIC SYMPTOMS OBTAIN
GLUCOSE, PROINSULIN , CPEPTIDE & INSULIN




                              +     SELECTIVE
  Acabose
 Octreotide
  Dietary
              -
              -
                                  ARTERIAL Ca++
                                  Stimulation test



 Counseling
              Pc resection: Insulinomo
                 Or Nesidioblastosis
                                        +
     Hyperinsulinemic Hypoglycemia



A.   Beta Cell Hyperplasia

                  OR

B. Overly Robust Insulin Secretion in Response
    to a Glucose Mixed Meal
   Controversy: Nesideoblastosis…or??

Service, Patti, Clancy and Alvarez:
 GLP-1 increase causes islet cell Hyperplasia

Meier examined Service’s pancreatic tissue and found
 NO beta cell mass increase

Therefore post prandial hypoglycemia after RNY is a
 combo of Dumping syndrome & increased Insulin
 Secretion
       Hyperinsulinemic Hypoglycemia

15 month after RNYGB allows for time for Islet Cells to
  increase in response to increased GLP-1 release from
  Ileum

OR GLP-1 increases Insulin sensitivity; and as the
 patient loses weight the increased Insulin sensitivity
 does not adapt to the extreme weight loss
     Finally – Symptomatic Hypoglycemia
                  most cases:
1. Post prandial hypoglycemia with neuroglycopenia
    & > one year after GB
2. Spontaneous correction of hypoglycemia
3. Nl fasting plasma Glu & Serum Insulin
4. Increased insulin at the time of hypoglycemia
5. Treated with Low Carbohydrate meal
           Internal Hernias - late
 DEFINITION: HERNIATION THROUGH
    MESENTERIC DEFECT 3-4%, usu late
   Increased with laparoscopic procedures
   Gastric Distention - IH until proven otherwise
   Pain may be only constant symptom: epigastric
    radiating to back usu mid>>luq
    intermittent increased with eating
    occas nausea and vomiting
   Negative Lab, Clinical diagnosis, OR confirmation
               Calcium Oxalate stones

 On 24 hr urine stone analysis you see increased
    oxalurea:
   Calcium Citrate needed to bind excess oxalate in the
    gut, otherwise the oxalate will absorb into the urine a
    combine with calcium to form stones.
   Ask dietician for low oxalate diet
   At least 1600 cc water/day
   Often told to dc calcium which is the wrong advise!
               Kidney Stone cont.

Ex.#1: Ca Ox Stone
         D24Oh = 36
         PTH 18
    ( continue ca.citrate same dose)
EX.#2: Ca Ox Stone
       D25OH = 18
       PTH 66
( needs increased calcium citrate & 1000 D)
          Post Op Care: Band
Band Nutrition
Medication management
Labs
Adjustments
                Gastric-BAND Post-Op Diet

 The First One to Four Weeks
      Liquids and very soft food (soup, yogurt, juices,
      jello, skim milk, etc.)
 Four to Six Weeks
     Slightly thicker diet.
     Gradually switch to solid food


 After Four to Six Weeks -- solid food :
     Eat 3 small meals a day
     Eat slowly and chew thoroughly
     Stop eating when feel full
     Do not drink while eating
     Avoid fibrous food, breads, rice
     Drink enough fluids during day
     Exercise 30 minutes a day
                          BAND Complications
 Early:
      Stomach perforation     1 (0.29%)
      Food intolerance       41 (11.7%)
      Pulmonary embolism      0
      Wound infection         0
      Intra-abdominal sepsis 1 (0.28%)
      Mortality               0




Source: Belachew, 1998.
                    Band Lifestyle

 Liquid breakfast will do – often coffee is it
 Patients manage their band
 If they choose caloric foods, their weight loss will be
  slower: the red zone: chocolate always goes down
 That you can tighten the band in the future is like a
  great Insurance policy
 Keep your doors open – let them come whenever
  they need!
 Watch out for tightening with menses and airplanes
  or URI/ cough/ infection
               Timing of adjustments?

 If your patient is not losing weight for two weeks,
  consider a fill. Keep them coming often in the
  beginning.
 Poor weight loss suggests continued hunger, lack of
  control and a band that is not tight enough or a
  band that is too tight and they are eating chocolate
  as it is easy …or ice cream
 Patients get discouraged see them! Orange or red
  zone? Weight gain could be either!
 Note as patient get close to appropriate tightness,
  they need more fills of very small amounts.
                 Band Adjustments

 A tool for a lifetime
 Band holidays?
 Too tight and slip? Will it readjust and why?
 Why you don’t remove all the fluid every time to
 check
           Band: Vomiting & reflux
 Vomiting/Reflux after banding is a band problem
  til proven otherwise.
 Eating late at night, taking pills after dinner cause
  reflux
 Everyone forgets and eats too fast sometime
 Is the band just too tight? On period, strep throat?
                  LATE BAND Complications


 Complications of the band:            3.2%
  Slippage              (herniation)   2.2%
  Erosion                              1.1%
 Complications of the port:            3.2%
  Infection                                   2.2%
  Twisting                                    0.5%
  Tube  defect                         0.5%
 Occlusion of the stoma:               2.2%


 Source: Weiner, 1999.
  Without Tool #1 Lifestyle,
           Tool #2 bypass or
Tool #3 lap band eventually break down


            45 MIN EXERCISE A DAY
       DESSERT PLATES & PROTEIN FIRST
                 NO SNACKING
       ACCOUNTABLE TO SCALE, FOOD LOG
               FAMILY SUPPORT
       EAT SLOW & SAVOR THE FIRST BITE
Controversy #1:Primary Care on a Different Page

 34 % Internists’s patients are morbidly obese
 Only 15% are referred to surgery
 Same docs believe 64% of surgery patients have good
  outcomes
 PCP concern over death and bad outcomes
 PCP poor understanding of improved QOL or
  changes in depression
 37% believe improved diabetes
Avidor Y, Still CD, Brunner M, Buchwalds J & H. Primary Care & Subspecialty Management, SOARD
       Why People do not keep showing up –
       Cleveland Center for Bariatric Surgery

79% see PCP instead
16% live too far ( 8-165 miles away)
11% insurance issues
9.4% doing fine and do not need help
7.9% too busy
5.1% post op class was too long
4.0% inconvenient time
USE A NURSE CASE MANAGER!!
  Hill & Wing – National Weight Control Registry

 Long term weight loss succeeders
 It gets easier years later
 45 minutes vigorous exercise most days
 Less eating out
 Exercising with someone you enjoy doing something
  you enjoy
 Accountable to oneself: scale, diet and exercise
Wing RR, McGuire MT, Hill JO, Seagle HM. Am J Clin Nutr 5;6(5) 1998
           Controversy #2: The Clock
  “ It doesn’t mean anything if it ain’t got that
        swing” Duke Ellington 1899-1974
We got rhythm: rhythm of eating, fasting, sleeping
and wakefulness
 A Circadian System
 organizes physiological
 processing, including
 metabolism in
 synchrony with the 24
 hour rotation of the
 earth.
   Rhythm: Alterations of feeding cycles – not
        necessarily the amount of food.
Circadian regulation is intimately connected to energy
  homeostasis

Numerous aspects of metabolism exhibit daily rhythmicity:
    circulating metabolites
    feeding related hormones
    ingestive behaviors

Sleep/Wake & Feeding/Fasting Cycle alterations
  contribute to gene mutations mixing up signaling for
  health and disease
               Bonnet Monkey
A normal
adolescent Bonnet
Monkey.
During its infancy,
its mom had
normal amounts of
a reliable food
source
Bonnet Monkey


During this
adolescent
Bonnet
Monkey’s
infancy, its
mother was
stressed by
unreliable food
availability
Late Night with NYU – the importance of sleep
            Example of a Light Clock:

 The availability of food and the risk of predators are
 tied into the light/ darkness cycle.

 Light from the eyes via the retino- hypothal drives
 behavior rhythms, locomotor activity and
 coordinates peripheral clocks

 RATS exposed to Constant light exhibited erratic
 metabolic functions and activity levels
Peripheral & central clocks:
  Leptin & SLEEP & NO NIGHT SNACKING


 Leptin is the hormone that is designed to turn on in
  response to food to make us stop eating – the satiety
  hormone.

 Leptin is primarily found in fat cells


 In the dark (sleep) via a relationship with Melatonin,
  Leptin promotes satiety allowing body maintenance:
  rejuvenate immune status, thyroid and other metabolic
  hormonal functions
 Leptin & SLEEP & NO NIGHT SNACKING


 At night the liver synthesizes glucose for energy


 If you eat late at night, this pattern is thrown off


 If you do not sleep the pattern is thrown off
                                 Sleep



 Sleep time = body rehab: immune, thyroid, Growth hormone, Sex
  hormone functions

 Shift workers statistically more obese


 Sleep restriction appears to affect secretion of and/or responsiveness to
  leptin causing increased appetite
  Controversy #3: The fat cell and weight regain
 Yoyo dieters & obese people in general
  have damaged fat cells

 Once a fat cell has swollen with an
  abnormal amount of fat, its internal
  mitochondrial structure is irreparably
  altered

 If you give fat or carbohydrates to
  damaged fat cells, they will preferentially
  store these substances as fat rather than
  efficiently burn these for energy.

 Then these damaged fat cells will hold
  onto the fat
          The fat cell and weight regain
 In order to get fat out of fat
  cells you need to take omega
  3s, protein and exercise,
  low/nonfat calcium and D,
  whole grains

 Sources of Omega 3 = all fish
  & flax ( plant )
Controversy #4: Low Glycemic for everyone?

           Insulin




                     insulin
Low Glycemic for everyone?
Controversy #5: The 200 year old Baked Potato
         Speed of eating & Diabetes
             Curbside Consult

 LISTEN
 INDIVIDUALIZE
 ENJOY THE FIRST BITE
 FAILURE IS NOT SHOWING UP
 SUCCESS IS SHOWING UP
 IT TAKES A VILLAGE OVER A LIFETIME

				
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