preoperative evaluation of the bariatric surgery patient eric i. rosenberg, md, msph, facp
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Preoperative Evaluation of the Bariatric Surgery Patient
Eric I. Rosenberg, MD, MSPH, FACP
Case #1“. . . evaluate for metabolic disorder”
“Super Super” Morbid Obesity
• 53 year-old woman
• 399 lbs, 4’ 10”, BMI 83.3
• Bariatric surgeon notes central obesity, abdominal bruises, buffalo hump
History
PMHx: Catatonic schizophreniaBipolar Disorder
PGynHx: G2 P2
Meds:
Allergies:
Fluoxetine, Risperidone
Ø
FH: Ø
SH:
ROS:
Disabled; some EtOH
Venous stasis, cellulitis
Exam
• BP 147/73, P 83
• Flat affect
• Moon facies
• Buffalo hump
• No muscle wasting, no striae, no bruising
Prior Studies – 8 months prior
TSH 3.7TSH 3.7141
3.83.8
106
2828
2525
0.70.78484
11.911.9
36369.39.3 282282
CaCa++ 9 9
Chest X-ray: normalChest X-ray: normal
ECG: normalECG: normal
Differential Dx for Severe Obesity
• Dietary
• Social/Behavioral
• Inactivity
• Iatrogenic
• Neuro-endocrine
What would you do next?
Key Issues for Bariatric Pre-Operative Evaluation
• When should you suspect a non-lifestyle associated etiology for morbid obesity?
• What is the most efficient diagnostic strategy to evaluate for a neuro-hormonal cause?
• What are the most important medical risks to this patient if she undergoes bariatric surgery?
Key Issues for Bariatric Pre-Operative Evaluation
• When should you suspect a non-lifestyle associated etiology for morbid obesity?
• What is the most efficient diagnostic strategy to evaluate for a neuro-hormonal cause?
• What are the most important medical risks to this patient if she undergoes bariatric surgery?
Severe Obesity = BMI 40
NHLBI 2000NHLBI 2000
Treatment Guidelines for Obesity
Prevalence of Severe Obesity is Increasing
Pharmacotherapy: only 3 to 5 kg Average Weight Loss
Bariatric Surgery Reduces Obesity-Associated Morbidity
Surgery May Improve Longevity
“Ideal” Bariatric Surgery Candidates
Cleve Clin J Med 2006;73(11).Cleve Clin J Med 2006;73(11).
HMO/Medicare Payment for Bariatric Surgery
• BMI > 40 for 2 to 5 years– BMI > 35 if CAD, DM, HTN, sleep apnea
• Repeated failures of supervised weight loss (6 months duration)
• Letter of medical necessity
• “Treatable metabolic causes ruled out”– “Thyroid panel”
– “adrenal disorders”
Roux-en-Y Combines Restriction with Malabsorption
Acute Complication Rates for Bariatric Surgery
Long Term Complications
• Anastomotic Stricture
• Marginal ulcers
• Bowel obstruction
• Cholelithiasis
• Nutritional Deficiencies
Nutritional Deficiencies are Common after Malabsorptive Procedures
• Iron
• Vitamin B-12
• Calcium
• Vitamin D
Multitamins will not adequately treat Multitamins will not adequately treat iron and B-12 deficienciesiron and B-12 deficiencies
Key Issues for Bariatric Pre-Operative Evaluation
• When should you suspect a non-lifestyle associated etiology for morbid obesity?
• What is the most efficient diagnostic strategy to evaluate for a neuro-hormonal cause?
• What are the most important medical risks to this patient if she undergoes bariatric surgery?
Possible Metabolic Causes of Obesity in Our Patient
• Hypothyroidism
• Hypothalamic condition
• Cushing’s Syndrome
• Polycystic Ovarian Syndrome
• Pseudohypoparathyroidism
This was my “non-clearance”…
IMPRESSION: A 53-year-old white female without any history of cardiopulmonary disease. Given her lifelong history of morbid obesity in association with and lack of history of diabetes and hypertension, I think it is unlikely that she has Cushing disease or other underlying metabolic disorder….
I think she is at high risk for perioperative delirium given her significant psychiatric history. I think that the surgical team will need to be cautious with administration of narcotics or hypnotics/sedatives.
But Could She Have Cushing’s Syndrome?
• Physical exam suggestive of hypercortisolism
–From severe obesity?
–From psychiatric distress?
–From alcoholism?
• No history of glucocorticoid use
Prevalence of Clinical Features of Cushing’s Syndrome• Obesity (90%)
• Neuropsychiatric (85%)
• Hirsutism (75%)
• Bruising (35%)
• Hypertension (85%)
• Diabetes (20%)
Greenspan’s Basic and Clinical Endocrinology, 8Greenspan’s Basic and Clinical Endocrinology, 8thth Edition. Edition.
Validity of Standard Screening Tests for Cushing’s Syndrome• Elevated midnight serum cortisol
–96-100% sensitivity, 100% specificity
• Overnight Dexamethasone Suppression–90-100% sensitivity, 40% specificity
• Elevated 24-hour urinary cortisol excretion
–100% sensitivity, 98% specificity
Accuracy of Screening Tests for Cushing’s Syndrome
J Clin Endocrinol Metab 88:2003.J Clin Endocrinol Metab 88:2003.
My Clinical Suspicion was High Enough to Screen for Cushing’sRECOMMENDATIONS:
1) “I ordered a midnight salivary cortisol test which is very sensitive and has high negative predictive value.”
Recommended Preoperative Testing for Bariatric Surgery
• Hematocrit
• Baseline Iron, B-12 levels
• TSH
• A1c (if diabetic control in doubt)
• Creatinine if appropriate
• Baseline ECG and other cardiopulmonary testing if suspect undiagnosed disease
8 Months later…
• Test #1: 0.155 ug/dL (normal <0.112)
• Test #2: quantity not sufficient
• Test #3: quantity not sufficient
• Test #4: quantity not sufficient
• Endocrine referral
Dexamethasone Suppression Test Rules-Out Cushing’s• 1mg Dexamethasone at 11PM to 12AM
• 8AM Cortisol level
–1mcg/dL
• <8% of patients with Cushing’s show suppression to < 2 mcg/dL
• 100% sensitivity if suppress to less than 1.2 mcg/dL
Take-Home Points
• Severe Obesity is increasingly prevalent
• Bariatric Surgery will increase in popularity
• Prospective Bariatric Surgery Patients need careful risk assessment and long-term follow-up for complications
• Consider appropriate screening for secondary causes if patient presents with characteristic history, signs
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