Medical Management of the Bariatric Surgery Patient

Jennifer Dooley, MD, FACP

Assistant Professor, Internal Medicine Department

Diplomat of the American Board of Obesity Medicine

• No disclosures

Objectives• Understand the benefits of and who qualifies for bariatric surgery

• Pre-Operative Assessment of the Obese Patient

• Review Types of Bariatric surgery with early and late complications

• General Follow-up Post-Op

Including nutritional and supplement needs

• Poor weight loss or weight re-gain after surgery

https://www.obesityserieslive.com/app/cme-auditorium/presentation/060717_OSL_obesity_CME

http://images.slideplayer.com/34/10215396/slides/slide_7.jpg

Gupta, Wang Treatment satisfaction with different weight loss methods among

respondents with obesity. Clin Obes. 2016 Apr;6(2):161-70

Adams. Weight and Metabolic Outcomes 12 Years after Gastric Bypass NEJM Sept 2017

https://www.nejm.org/doi/full/10.1056/NEJMoa1700459?query=recirc_curatedRelated_article

Mortality rate when performed at a Bariatric Surgery Center of Excellence: Bariatric Surgery: DeMaria Baseline data from ASMBS designated Bariatric Surgery Centers of

Excellence using the Bariatric Outcomes Longitudinal Database. Surgery for Obeisty and Related Diseases.

Dolan, et al The National Mortality Burden and Significant Factors Associated with Open and Laparoscopic Cholecystectomy: 1997-2006. J Gastro Surg 2009: 13:2292-2301

Lie SA, et al. Early postoperative mortality rate after 67548 total hip replacements Acta Ortho 2002 73(4):392-399

Ricciardi, et al. Volume Outcome Relationship for CABG in an Era of Decreasing Volume. Arch Surg 2008: 143(4):338-344

Adams, et al, Long-Term Mortality after Gastric Bypass Surgery NEJM 2007

Ikramuddin S, Korner J, Lee W, et al. Lifestyle Intervention and Medical Management With vs Without Roux-en-Y Gastric Bypass

and Control of Hemoglobin A1c, LDL Cholesterol, and Systolic Blood Pressure at 5 Years in the Diabetes Surgery Study. JAMA. 2018;319(3):266–278.

Schauer, et al. Bariatric Surgery versus Intensive Medical Therapy for Diabetes — 5-Year Outcomes NEJM 2017

Who is eligible?

• BMI >40 kg/m2

• BMI >35 kg/m2 with comorbidity

Diabetes

Hypertension

Obstructive Sleep Apnea / Obesity Hypoventilation Syndrome

Nonalcoholic Fatty Liver Disease (NAFLD) or Nonalcoholic Steatohepatitis (NASH

Pseudotumor Cerebri

Debilitating Arthritis

• Prior weight loss attempts

Other• Bariatric Seminar

• Insurance coverage for bariatric surgery

• Most require documentation of obesity for over 5 years

• Most require documented weight loss attempts for over 6 months

• Tobacco free at least 6 weeks

• Nutrition/Dietitian evaluation

• Psychological evaluation

No substance abuse within 6 months

No uncontrolled psych disorders

Compliant, competent, and motivated to change

Medical Preoperative Assessment• Glycemic Control:

A1c <8%

• Labs

CBC, CMP, FLP, B12, Fe, Folate Vit D, Ca, +/- TSH

• Medication review

Stop OCPs and HRT 1 month before surgery

BP and DM med review

• Tobacco cessation

• Cardiac evaluation

• Sleep screening

F/U polysomnography if positive

• GI evaluation, if symptoms

Esophagram, endoscopy

+/- H. pylori testing

• Counseled to avoid pregnancy

• Routine cancer screenings up to date

• Weight loss pre-op

Liquid diet 2 weeks prior to surgery

https://www.sleepmedicine.com/files/files/StopBang_Questionnaire.pdf

Morgenstern. Prevalence of OSA in USA Railway Workers. American Sleep Apnea Society 2016

http://amsleep.org/3211-2/

R. Carter III, D.E. Watenpaugh / Pathophysiology 15 (2008) 71–77

Pre-op Clearance Request

Stress Test Weight Limit Comments

Exercise Treadmill 300-400 lbs • Ability to exercise may

be impaired

Adenosine SPECT

(Thallium, sestamibi)

400 lbs • Difficult to interpret

due to false positives

(artifacts)

• Expensive

Dobutamine Echo 700 lbs • Limited Echo Windows

• Less Expensive

• Gives info on LVH, EF,

diastolic function and

right heart pressures

Adapted from Butsch. Bariatric Surgery. Blackburn Course in Obesity Medicine 2016

Sjöström Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects. N Engl J Med 2007; 357:741-752

Laparoscopic AdjustableGastric Band• Purely restrictive

• Highest weight regain

• May be appropriate in those who want less invasive surgery or less weight loss

• Multiple adjustments needed, high reoperation rate

• Complications Early:

Reflux

Band migration

DVT

• Complications Late:

• Reflux

• Pouch enlargement

• Esophageal dysmotility/dilation

• Band leakage

• Band erosion

Sleeve Gastrectomy

• Restrictive and metabolic

• Currently the most common bariatric surgery

• Avoid if pre-existing severe reflux

• Nausea and reflux

• Complications Early

GI Leak

Reflux

Nausea

DVT

• Complications Late:• Reflux

• Gastric dilation

• Stricture

• B12 deficiency

Roux-En-Y Gastric Bypass• Restrictive and malabosorptive

• “Gold Standard”

• Complications Early: Stricture

Marginal Ulcer

DVT

most common cause of mortality in perioperative period

Thiamine Deficiency

With persistent nausea and vomiting

Anastomotic Leak

Unexplained Tachycardia +/- Shoulder Pain

• Complications Late: Dumping Syndrome

Vasovagal symptoms with high carb meals

Bowel obstruction

Hernia

Marginal Ulcer

Enteroenteric fistulas

Bacterial Overgrowth

Oxalate Nephropathy

Gallstones

Vitamin deficiencies

Biliopancreatic Diversion with/without Duodenal Switch

• Malabsorptive

• Least commonly performed due to severe long term side effects

• Complications Early

GI Leak

Roux limb obstruction

• Complications Late

Diarrhea and flatulence

Dumping Syndrome

Electrolyte abnormalities

Liver failure

Gallstones

Renal stones

Highest risk for nutritional deficiencies:

B12, Folate, Fe

Ca, Vit D

Vitamins ADEK

Zinc, Copper, Selenium, Thiamine

T .

Postoperative Points

• Nutrition

• Comorbidities/Medication Follow-up

• Supplements

• Lab Follow-up

• Physical Activity

Nutrition• A minimal protein intake of 60 g/d and up to 1.5 g/kg ideal body weight per

day should be adequate

• Concentrated sweets should be eliminated from the diet after RYGB to minimize symptoms of the dumping syndrome

• Crushed or liquid rapid-release medications should be used instead of extended-release medications to maximize absorption in the immediate postoperative period

• Fluids should be consumed slowly, preferably at least 30 minutes after meals to prevent gastrointestinal symptoms, and in sufficient amounts to maintain adequate hydration (more than 1.5 liters daily)

Dumping Syndrome• Early Dumping

Can occur in up to 50% of RYGB patients

Rapid onset, usually within 15 minutes

Results from rapid emptying of food into the small intestine and due to the hyperosmolality of the food, rapid fluid shifts from the plasma into the bowel occur, resulting in hypotension and a sympathetic nervous system response

Patients often present with vasovagal symptoms, nausea, tachycardia, colicky abdominal pain, diarrhea

• Late Dumping (Postprandial Hyperinsulinemic Hypoglycemia [PHH]) Rare complication, occurs in 0.1-0.3% of patients

Occurs 1-3 hours after a carbohydrate-rich meal, months to years after surgery

The pathophysiology of PHH is not fully understood but likely includes alterations in multiple hormonal and glycemic patterns such as increase in incretin levels.

Symptoms same as above and documented hypoglycemia

• Most patients can avoid by limiting carbohydrate intake each meal

• Late dumping refractory to dietary modification may require need medication (ex. nifedipine, octreotide)

Comorbidity/Medication Follow-up

• Diabetes Regular close follow-up, as bariatric surgery is effective in some cases to cure diabetes

Immediately post-op, all medication should be adjusted due to liquid diet and risk for hypoglycemia (ex hold insulin secretagogues such as sulfonylureas)

• Hypertension Regular medication review with each visit

Needs may decrease with weight loss, variable with patients

Caution diuretics in immediate post-op period

• Hyperlipidemia Lipid levels and need for lipid-lowering medications should be periodically evaluated

• Sleep apnea

may be reassessed with a sleep study in 6 to 12 months after surgery to reassess the continuous positive airway pressure (CPAP) requirement.

• NSAID avoidance

Routine Supplementation for RYGB and Sleeve

• Multivitamins (MV) with iron Bariatric form 200% of daily recommend value or 2 OTC Complete MV

Chewable but NOT GUMMY VITAMINS

• Calcium Citrate 1200 to 1500 mg in divided doses 2 hours apart from iron supplementation

• Vitamin B12 (sublingual 500 mcg/day, intranasal 500 mcg/week, intramuscular 1,000 mcg/month or later oral 1000mcg/day)

• Vitamin D 3000 IU titrated to therapeutic 25- hydroxyvitamin D levels

• Iron 36 mg elemental Fe/day in MVs, sufficient for most

40-65 mg needed for menstruating women and those at risk for anemia

Ferrous sulfate 325mg daily (65mg elemental Fe) or Ferrous fumarate two 27 mg chewable tabs daily

Supplements should be chewable/easily absorbable the first 3 to 6 months

https://www.consumerhealthdigest.com/health-conditions/gastrointestinal-tract.html

Water Soluble Vitamins

Katz. Nutrition in Clinical Practice 3rd Edition Wolters Kluwer 2015

Butch. Nutrition Assessment and Therapy. Blackburn Obesity Board Review 2016

Parrott. ASMBS Nutritional Guidelines for the Surgical Weight Loss Patient 2016 Update: Micronutrients

VitaminClinical Findings of Deficiency Absorption Test Supplements Replacement Other

Thiamine (B1)

Wernicke-Korsakoff: confabulation, ophthalmoplegia, ataxia Wet Beriberi:Cardiomegaly, CHF, tachycardiaDry Beriberi:peripheral polyneuropathy

Proximal Jejunum

Serum Thiamine < 80mcg

Multivitamin with 100% RDA

500 mg IV TID 2 days then 250 mg IV/IM daily for 5 days then 100mg daily

If severe N/V, can be quickly precipitated

Cobalamin (B12)

Peripheral and central neuropathy Pernicious anemia ParesthesiasUnsteady gait Delusions

Terminal ileum

Gastric acid detaches B12 from binding protein and IF required for absorption

B12 < 250pg/mLMMA > 40mmol/L

500-1000 mcg daily 1000 mcg IM PPIs and metformin increase deficiency risk

Folate Glossitis, stomatitis Diarrhea, malabsorption

Duodenum and jejunum

Decreased RBC folate

Multivitamin with 100% RDA

800 mcg/day

Biotin Alopeciaseborrheic dermatitis nausea and vomiting depression glossitis

Duodenum jejunum colon

Serum biotin levels not reliable marker

Multivitamin with 100% RDA

500-1000mcg/day Many patients will take for hair loss High doses not associated with toxicity

Fat Soluble Vitamins

VitaminClinical Findings of Deficiency Absorption Test Supplements Replacement Other

Vitamin A Night blindness Follicular hyperkeratosis

Duodenum jejunum

Plasma Retinol < 25mg/dL Multivitamin 5,000-10,000 IU daily

100,000 IU can result in toxicity (HA, vomiting, hepatic injury, birth defect)

Vitamin D Osteomalacia: bone pain, proximal muscle weakness

Small bowel 25-OH Vitamin < 32m g/dL

2,000-3000 IU 50,000 IU weekly

Vitamin E Hyporeflexia, gait disturbance, muscle weakness, decreased proprioception, ophthalmoplegia, nystagmus, hemolytic anemia

Duodenum jejunum

Plasma alpha tocopherol < 5 mg/dL

Multivitamin 100-400 mg daily

Interferes with Vit K metabolism and can prolong PT at higher doses

Vitamin K Ecchymoses and Bleeding small and large intestine

Prolonged PT Multivitamin 1 mg/d

Katz. Nutrition in Clinical Practice 3rd Edition Wolters Kluwer 2015

Butch. Nutrition Assessment and Therapy. Blackburn Obesity Board Review 2016

Parrott. ASMBS Nutritional Guidelines for the Surgical Weight Loss Patient 2016 Update: Micronutrients

MineralsMineral Clinical Findings of Deficiency Absorption Test Supplements Replacement Other

Calcium Osteoporosis HypoparathyroidismMuscles crampsTetany Paresthesia

Duodenum and proximal jejunum

Decreased CalciumIncreased PTH

1200-2000mg/d in divided doses 500-600mg/d

IV if symptomatic Calcium Citrate is preferred early post-op as it is chewable and does not need HCl for absorption

Iron Microcytic AnemiaPallor Fatigue Pica Glossitis Restless Leg

Duodenum and proximal jejunum

Decreased Ferritin (acute phase reactant) Low Fe Elevated TIBC

36 mg elemental Fe/day (the amount found in 2 MVs)

40-65 mg needed for menstruating women and those at risk for anemia

Take iron and Calcium 2 hours apart

150–200 mg of elemental iron daily

If unresponsive to oral therapy, IV infusion should be administered

Ferrous sulfate 325mg daily (65mg elemental Fe)

Ferrous fumarate 27 mg elemental Fe chewable tabs 2 daily

Niferex 150mg elemental iron per capsule

Zinc Impaired taste and smellPoor wound healing Dry, scaly, hperpigmented skin Cellular immune deficiency

Duodenum and proximal jejunum

Serum zinc level not reliable but can be checked

Multivitamin with 60 mg zinc

Insufficient evidence to make a dose-related recommendation for repletion

Estimated dose 60 mg elemental zinc (eg 220mg zinc sulfate) orally BID

Chronic intake of zinc may lead to copper deficiency

Supplement 1 mg copper for every 8–15 mg of elemental zinc to prevent copper deficiency

Copper AnemiaNeutropeniaMenke’s kinky hairPoor wound healingMyeloneuropathy

Stomach and Duodenum

Serum Copper < 70 mcg/dL

Multivitamin with 2-4 mg copper

2.5mg IV x 5 days

Katz. Nutrition in Clinical Practice 3rd Edition Wolters Kluwer 2015Butch. Nutrition Assessment and Therapy. Blackburn Obesity Board Review 2016Parrott. ASMBS Nutritional Guidelines for the Surgical Weight Loss Patient 2016 Update: Micronutrients

Lab follow-up

• ASMBS Recommendations:

CBC, CMP each visit

FLP 6-12 months based on risk and therapy

B12 Q3-6 months for the 1st year then annually

25-vitamin D, PTH, iron studies, folic acid (RBC folic acid optional) Q3-6 months for the 1st year then annually

Vitamin A if BPD (optional with RYGB) Q3-6 months for 1st year then annually

Copper, zinc, thiamine only with specific findings

• DEXA at 2 years

Physical Activity

• Exercise Goals:

150 minutes (30 minutes, 5 days/week) has been shown to be effective for weight maintenance

300 minutes (60 minutes, 5 days/week) has been shown to be effective for weight loss

Incorporate strength training 2 to 3 days/week

Erlanger Metabolic & Bariatric Surgery Center Patient Manual 2018

Other• Avoid pregnancy for 1 year post-op

Fertility increases post-op (PCOS improves)

• Gout

May be exacerbated after RYGB

• Alcohol

accelerated alcohol absorption after RYGB and LSG

• Mental Health

Depression may improve or worsen

SSRI absorption decreased after RYGB

Support group encouraged

Hamad , et al. The effect of gastric bypass on the pharmacokinetics of serotonin reuptake inhibitors.. Am J Psychiatry. 2012 Mar;169(3):256-63

Weight Regain• Nutrition

• Physical Activity

• Pharmacotherapy

Heymsfield SB, Wadden TA. N Engl J Med 2017;376:254-266.

Medications Approved by the Food and Drug Administration for Long-Term Weight Management

References1. Gupta, Wang Treatment satisfaction with different weight loss methods among respondents with obesity. Clin Obes. 2016 Apr;6(2):161-70. 2. https://www.obesityserieslive.com/app/cme-auditorium/presentation/060717_OSL_obesity_CME Accessed April 2018.3. Adams. Weight and Metabolic Outcomes 12 Years after Gastric Bypass NEJM Sept 20174. Mortality rate when performed at a Bariatric Surgery Center of Excellence: Bariatric Surgery: DeMaria Baseline data from ASMBS designated

Bariatric Surgery Centers of Excellence using the Bariatric Outcomes Longitudinal Database. Surgery for Obesity and Related Diseases. 5. Dolan, et al The National Mortality Burden and Significant Factors Associated with Open and Laparoscopic Cholecystectomy: 1997-2006. J

Gastro Surg 2009: 13:2292-23016. Lie SA, et al. Early postoperative mortality rate after 67548 total hip replacements Acta Ortho 2002 73(4):392-3997. Ricciardi, et al. Volume Outcome Relationship for CABG in an Era of Decreasing Volume. Arch Surg 2008: 143(4):338-3448. Adams, et al, Long-Term Mortality after Gastric Bypass Surgery NEJM 2007 9. Ikramuddin S, Korner J, Lee W, et al. Lifestyle Intervention and Medical Management With vs Without Roux-en-Y Gastric Bypass and Control of

Hemoglobin A1c, LDL Cholesterol, and Systolic Blood Pressure at 5 Years in the Diabetes Surgery Study. JAMA. 2018;319(3):266–278. 10. Schauer, et al. Bariatric Surgery versus Intensive Medical Therapy for Diabetes — 5-Year Outcomes NEJM 201711. https://www.sleepmedicine.com/files/files/StopBang_Questionnaire.pdf Accessed Oct 201812. Morgenstern. Prevalence of OSA in USA Railway Workers. American Sleep Apnea Society 2016 via http://amsleep.org/3211-2/13. R. Carter III, D.E. Watenpaugh / Pathophysiology 15 (2008) 71–7714. Butsch. Bariatric Surgery. Blackburn Course in Obesity Medicine 201615. Sjöström Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects. N Engl J Med 2007; 357:741-75216. https://www.consumerhealthdigest.com/health-conditions/gastrointestinal-tract.html Accessed Oct 201817. Katz. Nutrition in Clinical Practice 3rd Edition Wolters Kluwer 201518. Butch. Nutrition Assessment and Therapy. Blackburn Obesity Board Review 201619. Parrott. ASMBS Nutritional Guidelines for the Surgical Weight Loss Patient 2016 Update: Micronutrients20. Erlanger Metabolic & Bariatric Surgery Center Patient Manual 201821. Hamad , et al. The effect of gastric bypass on the pharmacokinetics of serotonin reuptake inhibitors.. Am J Psychiatry. 2012 Mar;169(3):256-6322. Apovian C, et al. Pharmacological Management of Obesity: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2015; 100

(2): 342-362.23. Machineni S. Pharmacotherapy. Blackburn Course in Obesity Medicine 201624. Leslie. Weight gain as an adverse effect of some commonly prescribed drugs: a systematic review. QJM 2007: 100(7):395-404.25. Heymsfield SB, Wadden TA. N Engl J Med 2017;376:254-266