Bariatric Surgery

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Exploring bariatric surgery

Learn the basics of four common surgical West Virginia) had an obesity rate of 35% or more adults. The overall prevalence of options for adult obesity treatment when diet adult obesity is 39.8%. For the childhood and exercise have failed to produce significant prevalence of obesity, see A closer look at weight loss. pediatric obesity. The best method for weight loss, By Lisa Lockhart, MHA, MSN, RN, NE-BC, and weight control, and improved overall Charlotte Davis, BSN, RN, CCRN health and well-being is a healthy, natural diet along with regular exercise. Patients Obesity is defined as an increased should attempt dietary modification and amount of body weight from fat, muscle, a physician-supervised exercise program bone, or body water compared with spe- before considering surgical weight loss cific standards. Body mass index (BMI) is options. For patients for whom other a measurement of adult body fat based efforts have failed, bariatric surgery has on height and weight. According to the become a common weight loss treatment. National Institutes of Health, BMI should be utilized as a screening tool for both Biomechanics overweight and obesity during routine Bariatric surgery works by restricting and acute healthcare encounters. A BMI food intake, reducing food absorption, or of less than 18.5 kg/m2 is considered altering ghrelin production. underweight; normal weight, 18.5 to 24.9 Restrictive surgeries reduce the func- kg/m2; overweight, 25 to 29.9 kg/m2; tional size of the stomach, limiting the and obese, 30 kg/m2 or greater. amount of food the stomach can hold. According to the World Health Organi- This makes the patient feel full after eat- zation, over 600 million adults worldwide ing a smaller meal. Restrictive surgeries are obese and 2.8 million people die annu- include gastric banding, gastric bypass ally because of complications related to (also known as Roux-en-Y), and sleeve obesity. Obese individuals are at higher gastrectomy. Preoperatively, most patients risk for asthma, sleep apnea, metabolic can hold up to four cups of food in their syndrome, hypertension, atherosclerosis, stomach, whereas after surgery, the stom- heart disease, diabetes mellitus, high low- ach may hold one cup or less. density lipoprotein cholesterol, and spe- Reducing the absorption of food is cific types of cancers. achieved by bypassing a portion or most Obesity is a common health problem in of the small intestine where nutrients, the United States. According to the CDC, including fat and most calories, are in 2016 all states had an obesity rate of at absorbed. Biliopancreatic diversion with least 20% of adults. Five states (Alabama, duodenal switch (BPD-DS) is a procedure Arkansas, Louisiana, Mississippi, and that reduces absorption.

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Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. ANIMATED HEALTHCARE LTD / SCIENCE PHOTO LIBRARY / SCIENCE PHOTO LTD HEALTHCARE ANIMATED Get connected to www.NursingMadeIncrediblyEasy.com. See page 27. Often referred to as the hunger hor- (see Four types of bariatric surgery). There mone, ghrelin is a hormone-releasing are also FDA-approved medical devices peptide that’s excreted primarily in the to treat obesity (see Medical devices for stomach and synthesized in the hypothal- obesity treatment). amus. It’s responsible for energy balance within the body and also the sensation Gastric banding of hunger. By decreasing ghrelin produc- Adjustable gastric banding is a restrictive tion, not only is the feeling of hunger surgical procedure involving laparoscopic decreased, but also the frequency of hun- placement of a band that encircles the ger sensations. Surgical procedures that upper portion of the stomach to create a reduce stomach mass decrease ghrelin small stomach pouch or reservoir, which production. can hold approximately one-half cup of food. The band is connected to a subcu- Four common types taneous infusion port that’s surgically The four most common bariatric surgical secured to the abdominal wall under procedures are gastric banding, gastric the subcutaneous tissue. A connection bypass, sleeve gastrectomy, and BPD-DS tube links the band to the port, which

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Gastric banding Gastric bypass

Esophagus Excluded portion of stomach Gastric pouch Proximal pouch of stomach

Adjustable gastric band “Short” intestinal Roux limb

Pylorus

Stomach

Port

Duodenum

Sleeve gastrectomy BPD-DS

LLivLiverveerr Stomach pouch

Bile duct

Gastric “sleeve” Pylorus

Colon

Excised stomach

Common limb Biliopancreatic limb

Nettina SM. Lippincott Manual of Nursing Practice. 10th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013.

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BMI percentile is preferred for children, adoles- In a 2016 study, combined overweight and obe- cents, and young adults ages 2 to 20 because sity rates for Tennessee were 37.7% for children it takes into account that they’re still growing ages 10 to 17. and growing at different rates depending on Considerations for overweight or obese chil- their age and sex. Healthcare professionals use dren include the effects of bullying and social growth charts to determine whether a child’s isolation, such as depression, low self-esteem, weight falls into a healthy range for his or her and self-harm or suicide. height, age, and sex. Children with a BMI at or above the 85th percentile and less than the Bonus content 95th percentile are considered overweight. For more information on pediatric obesity, including weight loss Children at or above the 95th percentile are treatment options for children and adolescents, read “The Growing considered obese. Problem of Pediatric Obesity” from our November/December 2017 issue at According to the CDC, obesity affects 18.5% http://journals.lww.com/nursingmadeincrediblyeasy/Fulltext/2017/11000/ of children in the United States; 13.9% of high The_growing_problem_of_pediatric_obesity.7.aspx. school students meet the BMI criteria for obesity. can be accessed with a sterile needle to remaining stomach and pyloric sphinc- either add or remove sterile saline. As ter are bypassed, and the duodenum is more fluid is added, greater restriction is then attached to the lower portion of the achieved. jejunum. The duodenum provides sup- With the adjustable gastric band, port by being a portal for bile drainage. there’s no interruption of bowel integ- Less nutrients and calories are absorbed rity; all nutrients are absorbed normally. because a portion of the small intestine The band slows the passage of ingested is bypassed. food into the larger distal portion of the A complication unique to this proce- stomach. The degree of restriction affects dure is malabsorption, or “dumping,” the volume of food that can be consumed syndrome, which occurs when the small at one time, as well as the amount of intestine can’t absorb nutrients and may time it takes for food to leave the pouch. result in abdominal pain, diarrhea, sweat- Gastric bands may be adjusted in the ing, and light headedness. The main risks clinic setting or under fluoroscopic associated with gastric bypass are anas- guidance. tomosis site leakage, post-op blood clot Gastric bands have the benefit of formation, and hernia. being 100% reversible. The most com- Gastric bypass results in an average mon complications include infection, loss of 65% excess weight. band erosion, slipping of band placement, leakage around the band site, and bowel Sleeve gastrectomy perforation. With this procedure, the surgeon dis- Gastric banding results in an average sects the superior aspect of the stomach, loss of 49% excess weight after 3 years. making a restrictive pouch-like tube, similar to the shape of a banana. The Gastric bypass pouch holds less food and secretes less During this procedure, the surgeon cre- ghrelin. The remaining stomach (80%) ates a small pouch that can only hold is surgically removed. The benefit of approximately 30 mL of food or fluid. sleeve gastrectomy is that it limits ca- The pouch is located at the top of the loric intake but doesn’t bypass the intes- stomach, near the esophagus, and at- tine, which means nutrient absorption tached directly to the jejunum. The isn’t affected. www.NursingMadeIncrediblyEasy.com March/April 2018 Nursing made Incredibly Easy! 27

Besides the gastric band, there are three other drains the food before it’s fully broken down FDA-approved devices for obesity treatment: and absorbed by the body. The patient then gastric balloon systems, a gastric emptying sys- manually empties the external reservoir into tem, and an electrical stimulation system (vagal a toilet or another receptacle. After drain- blocking therapy). age is complete, the patient flushes his or Gastric balloon systems her stomach with water by squeezing the reservoir and drains the stomach a second There are three types of gastric balloons time. The gastric emptying system removes approved for surgical weight loss, typically approximately 30% of consumed calories. placed in an outpatient endoscopy setting The gastric emptying system is indicated with minimal sedation. During the procedure, a for adults age 22 or older with a BMI of 35 single or dual gastric balloon is placed inside to 55 kg/m2 the stomach via the mouth. Once placed within for whom nonsurgical weight- loss therapy has failed. It’s contraindicated the stomach, the gastric balloon(s) is inflated in patients with abnormal GI anatomy; ane- with sterile saline to reduce the volume of food mia or a diagnosed eating disorder; a history that can be consumed, which results in weight of previous gastric surgery, inflammatory loss. Gastric balloons can only stay in place for bowel disease, gastric ulcer, untreated H. 6 months. At that time, the balloon(s) is endo- Pylori infection, uncontrolled hypertension, scopically removed with no structural damage cardiovascular disease, or coagulation dis- occurring. orders; those who are pregnant or lactating; Gastric balloon systems are indicated and individuals with a physical or mental for adults who have a BMI of 30 to 40 kg/ disorder that may interfere with therapy m2 for whom diet and exercise have failed. They’re contraindicated in patients who compliance. have abnormal gastrointestinal (GI) function Complications include gastric leakage from or anatomy, or untreated H. pylori infection; the internal drain that’s attached to the external those who take nonsteroidal anti-inflamma- port. tory drugs or anticoagulation medications; It’s recommended that the gastric emptying those who’ve had previous gastric proce- system is used together with lifestyle therapy dures; and individuals with existing eating and continuous monitoring. disorders. Electrical stimulation system Complications include injury to the esopha- The electrical stimulation system is a recharge- gus with insertion, bacterial growth in the bal- able pacemaker-like implant that intermittently loon leading to infection, and obstruction. blocks intra-abdominal vagus nerve signals, It’s recommended that gastric balloon sys- which disrupts the transmission of messages tems be complemented with an exercise plan, involving food intake and processing between along with counseling and nutritional support the brain and stomach. The implant is placed in from the patients’ healthcare team. a minimally invasive outpatient procedure and Gastric emptying system the patient’s anatomy isn’t altered or restricted. The gastric emptying system consists of a This system is indicated for adults with a BMI surgical drain that’s placed into the upper of 40 to 45 kg/m2 (or 35 to 39.9 kg/m2 with an aspect of the stomach. The drainage tube obesity-related comorbidity) for whom a super- exits the abdominal wall through an exter- vised weight management program within the nal port that secures the drainage tube in past 5 years has failed. It’s contraindicated in place. The external port links the drainage patients with hiatal hernia, portal hypertension, tube to an external reservoir. The drainage cirrhosis, and esophageal varices. device remains clamped while the patient is Surgical site complications may occur; eating. About 20 minutes after eating, the patients may experience pain at the device patient attaches an external connector and site, nausea, heartburn, belching, and difficulty tubing to the port, opens the port valve, and swallowing.

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Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. A complication unique to sleeve is even more important for patients gastrectomy is the potential for gastric who are obese due to increased risk leakage, typically occurring at the staple of respiratory complications and deep site within the first month post-op. This vein thrombosis, along with comor- can lead to serious complications from bidities associated with obesity such as peritonitis. Leakage is considered either hypertension. type I (nonclinical) or type II (requiring Common pre-op screening includes a surgical intervention). Other concerns chest X-ray; ECG; labs, such as a compre- include post-op complications, such hensive metabolic panel, complete blood as infection, blood clot formation, and cell count with differential and platelets, bleeding. thyroid function test, and amylase and Sleeve gastrectomy results in an aver- lipase; and a psychiatric evaluation (for age loss of 56% excess weight. procedures that alter the anatomy, it’s important that patients understand the Pre-op BPD-DS permanence of their decision). instructions With BPD-DS, the surgeon begins by Depending on the patient’s spe- performing a sleeve gastrectomy and cific health history and the existence of may include then removes the dissected/excess por- comorbidities, additional testing may smoking tion of the stomach. The pyloric sphinc- be required, such as an echocardiogram, ter valve that releases food to the small abdominal ultrasound, or esophago- cessation, intestine is left, along with the duode- gastroduodenoscopy; testing for Helico- increased num. The small intestine is then divided bacter pylori; a complete cardiac profile at the duodenum (first one-third of the and cardiac clearance; and endocrine activity, the small intestine) and directly attached to testing. introduction the ilium (last portion of the small intes- Pre-op instructions may include tine). The medial ascending small intes- smoking cessation, increased activ- of protein into tine that’s been dissected isn’t removed; ity, and the introduction of protein the diet, and it’s reattached to the end of the intestine and protein supplements into the diet. where its primary function is to drain Presurgical weight loss may be recom- presurgical bile and allow pancreatic digestive juices mended; 10% pre-op weight loss will weight loss. to flow directly into this portion of the decrease liver fattiness and abdominal intestine. size, increase protein intake for muscle With BPD-DS, food bypasses most and tissue preservation, and prepare the of the small intestine without being patient for the post-op diet routine. The absorbed, and calories and nutrients are patient will also be asked to meet with limited. With the gastric sleeve reduc- nutritional counselors and bariatric case ing food intake volume and absorption managers. of ingested food dramatically reduced, An anesthesia consultation is needed weight loss is achieved. before surgery to review the patient’s Complications include gastric leaking medical history; previous anesthesia reac- and chronic malabsorption syndrome. tions; food and drug allergies; and current Surgical risks includes infection, blood medication regimen, including prescrip- clot formation, and bleeding. tions, over-the-counter drugs, and herbal BPD-DS results in an average loss of supplements. 73% excess weight after 2 years. A physical exam of the patient’s oral cavity will be conducted to assess for Preparation structural anomalies in the pharynx, hard As with all surgical procedures, a com- palate, tonsils, and tongue, which can plete pre-op evaluation is required. This increase the risk of airway complications www.NursingMadeIncrediblyEasy.com March/April 2018 Nursing made Incredibly Easy! 29

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. during surgery. This allows the anesthesi- Patients who’ve had laparoscopic sur- ologist or certified registered nurse anes- gery will typically have six to eight small thetist to strategically plan and have addi- incisions that are covered by wound clo- tional supplies present to safely manage sure strips. Inform the patient that these the patient’s airway during the procedure. strips should be allowed to fall off normally, which can take approximately 5 to Post-op care 7 days. Perform wound care as ordered by Nurses provide the same basic post-op the healthcare team. care for bariatric surgery patients as To minimize postsurgical complica- with other surgical patients, including tions, promote early ambulation and monitoring vital signs to ensure that the progressively increasing physical activity. patient remains hemodynamically stable. After surgery, patients will progressively Monitor the patient’s oxygen level and advance their diet from liquids to solids provide airway support and mainte- over several weeks’ time. nance as needed. Frequently monitor the patient’s level of consciousness and Emotional wellness immediately report alterations to the All bariatric surgery patients should be healthcare team. Frequently assess the prepared for the post-op physical, life- patient’s pain level using the healthcare style, and emotional changes that will oc- Providing organization’s approved pain assess- cur. Because many patients utilized food preparatory ment scoring tool. When administering as a coping mechanism, they may poten- commonly ordered post-op medications, tially struggle with emotional challenges education and such as analgesic, opioid, and anti- as that coping mechanism is removed. a supportive inflammatory medications, always assess Patients will have to find healthy options for potentiating effects. to cope with stress. environment Gastric bypass procedures can be per- Pre- and post-op care should include are keys formed laparoscopically unless there are counseling and/or support group factors that require an open approach, membership. Education on the changes to post-op such as liver size, abdominal girth, or in lifestyle and diet, and the possible phys- success. other comorbidities. Patients who aren’t ical and emotional changes that can arise, eligible for laparoscopic surgery may is needed for both the patient and his or have open surgery, resulting in an upper her family/friends. Providing preparatory midline abdominal incision that may education and a supportive environment be closed with skin staples, which are are keys to post-op success. typically removed 7 to 10 days post-op. Cleanse the surgical incision with an anti- A step ahead septic cleanser as prescribed. Inspect the As bariatric surgery continues to im- surgical incision line to ensure that the prove the quality of life for our patients, tissue is healing and well approximated. we must be armed with up-to-date infor- Frequently assess skin integrity at the mation that enables us to care for these surgical site for the presence of serous, patients more effectively, answer ques- serosanguinous, or bloody fluids. Visu- tions and concerns more knowledgably, ally inspect the tissue that surrounds and help improve positive outcomes. ■ the surgical site for symptoms of infec- REFERENCES tion, such as erythema, edema, and pain. Anderson B, Gill RS, de Gara CJ, Karmali S, Gagner Lightly palpate the tissue to assess for M. Biliopancreatic diversion: the effectiveness of duodenal switch and its limitations. Gastroenterol Res Pract. the presence of abnormal firm areas that 2013:974762. may be abscess pockets or an evolving CDC. Adult obesity prevalence maps. www.cdc.gov/ hematoma. obesity/data/prevalence-maps.html.

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Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. CDC. Prevalence of obesity among adults and youth: of randomized controlled trials. Obesity (Silver Spring). United States, 2015-2016. www.cdc.gov/nchs/products/ 2013;21(12):2422-2428. databriefs/db288.htm. StateofObesity.org. The state of obesity in childhood. Fryar CD, Carroll MD, Ogden CL. Prevalence of over- https://stateofobesity.org/childhood. weight and obesity among children and adolescents: Tamboli RA, Sidani RM, Garcia AE, et al. Jejunal admin- United States, 1963-1965 through 2011-2012. www.cdc. istration of glucose enhances acyl ghrelin suppres- gov/nchs/data/hestat/obesity_child_11_12/obesity_ sion in obese humans. Am J Physiol Endocrinol Metab. child_11_12.htm. 2016;311(1):E252-E259. Hill JO, Wyatt HR, Peters JC. Energy balance and obesity. U.S. Food and Drug Administration. Obesity treatment Circulation. 2012;126(1):126-132. devices. www.fda.gov/MedicalDevices/Products Hoelscher DM, Kirk S, Ritchie L, Cunningham-Sabo L, andMedicalProcedures/ObesityDevices/default.htm. Academy Positions Committee. Position of the Academy van Geel M, Vedder P, Tanilon J. Are overweight and of Nutrition and Dietetics: interventions for the preven- obese youths more often bullied by their peers? A meta- tion and treatment of pediatric overweight and obesity. analysis on the correlation between weight status and J Acad Nutr Diet. 2013;113(10):1375-1394. bullying. Int J Obes (Lond). 2014;38(10):1263-1267. Mayo Clinic. Guide to types of weight-loss surgeries. Wang Y, Cai L, Wu Y, et al. What childhood obesity www.mayoclinic.org/tests-procedures/bariatric-surgery/ prevention programmes work? A systematic review and in-depth/weight-loss-surgery/art-20045334. meta-analysis. Obes Rev. 2015;16(7):547-565. National Heart, Lung, and Blood Institute. Overweight World Health Organization. 10 facts on obesity. www. and obesity. www.nhlbi.nih.gov/health-topics/over- who.int/features/factfiles/obesity/en. weight-and-obesity. Ogden CL, Carroll MD, Lawman HG, et al. Trends in Lisa Lockhart is the Emergency Services Director at KentuckyOne obesity prevalence among children and adolescents in Health, Saint Joseph Health System, in Lexington, Ky., and a the United States, 1988-1994 through 2013-2014. JAMA. Nursing made Incredibly Easy! Editorial Board Member. Charlotte 2016;315(21):2292-2299. Davis is a Surgical-Trauma ICU Nurse Educator at Ocala Regional Medical Center in Ocala, Fla., a Clinical Adjunct Faculty Member at Praveenraj P, Gomes RM, Kumar S, et al. Management Clayton State University in Morrow, Ga., and the Clinical Editor of of gastric leaks after laparoscopic sleeve gastrectomy Nursing made Incredibly Easy! for morbid obesity: a tertiary care experience and design of a management algorithm. J Minim Access Surg. The authors and planners have disclosed no potential conflicts of 2016;12(4):342-349. interest, financial or otherwise. Sobol-Goldberg S, Rabinowitz J, Gross R. School- based obesity prevention programs: a meta-analysis DOI-10.1097/01.NME.0000529948.68840.94

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