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Bariatric Surgery 1.0 ANCC CONTACT HOUR 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. 24 Nursing made Incredibly Easy! March/April 2018 www.NursingMadeIncrediblyEasy.com 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 www.NursingMadeIncrediblyEasy.com March/April 2018 Nursing made Incredibly Easy! 25 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. Four types of bariatric surgery 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 LiverLLivveerr 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. 26 Nursing made Incredibly Easy! March/April 2018 www.NursingMadeIncrediblyEasy.com Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. A closer look at pediatric obesity 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 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. Medical devices for obesity treatment 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.
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