Bariatric Surgery Five of the Most Common Procedures and Nursing Implications for Pre- and Postoperative Care

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Outcomes and Complications After Bariatric Surgery Five of the most common procedures and nursing implications for pre- and postoperative care.

OVERVIEW: Bariatric surgery is an effective and increasingly common treatment for obesity and obesity- related comorbidities. There are currently two major categories of such surgery, grouped according to the predominant mechanism of action: restrictive procedures, such as vertical banded gastroplasty and adjustable gastric banding; and malabsorptive procedures with a restrictive component, such as Roux-en-Y gastric bypass, vertical sleeve gastrectomy, and biliopancreatic diversion with duodenal switch. In general, the more complex the procedure, the better the results in terms of weight loss; but there’s evidence that more complex procedures also have higher morbidity and mortality rates. This article outlines five of the most common procedures, discusses the outcomes and complications of bariatric surgery, and describes the nursing implications for pre- and postoperative patient care.

Keywords: bariatric surgery, obesity, weight loss surgery, weight reduction

f you haven’t already cared for a patient who obesity of 39%, while that for overweight and has undergone bariatric surgery, it’s likely that obesity combined is 68%.1 (For precise definitions Iat some point in your nursing career, you will. of obesity and overweight, see Terms Defined.2) Obesity has been shown to adversely affect all body People who are obese are at greater risk for numer- systems—and prevalence rates for obesity and over- ous illnesses, including type 2 diabetes, hyperten- weight stand at record highs in this country. Recent sion, coronary heart disease, stroke, osteoarthritis, data from the National Health and Nutrition Ex- cholelithiasis, sleep apnea, and certain types of amination Survey yield an estimated prevalence for cancers, among others.3, 4 Obesity may also have

26 AJN ▼ September 2012 ▼ Vol. 112, No. 9 ajnonline.com By Lauren E. Gagnon, BSN, RN, and Emily J. Karwacki Sheff, MS, FNP-BC, CMSRN

psychological and psychosocial consequences. For example, people who are obese often experience prejudice, discrimination, and psychological abuse from coworkers, family members, friends, and strangers, making it harder for them to maintain personal relationships.5, 6 They are also at higher risk for anxiety and depression.7-9 Probably for all of these reasons and more, bariatric surgery is becoming increasingly popular. In for older patients because of their higher risk 1998, an estimated 13,365 bariatric procedures were of complications, bariatric surgery has been performed in the United States; by 2007, that num- shown to be safe for many patients over the ber had increased to approximately 200,000.10 The age of 60.21, 22 American College of Physicians recommends that Bariatric surgery may be contraindicated for surgical intervention be considered for patients with people who have extremely high operative risk a body mass index (BMI) of 40 kg/m2 or greater factors such as severe congestive heart failure who have had previous unsuccessful attempts at or unstable angina. Patients who are unable weight loss and have obesity-related comorbidities.11 to understand the surgical risks and postoper- Furthermore, the American Diabetes Association rec- ative maintenance requirements, those who ommends that patients with a BMI of 35 kg/m2 or are active substance abusers, those with sig- greater and type 2 diabetes also be considered for nificant psychopathology (such as psychosis), bariatric surgery, especially if the diabetes has not and those with under- or untreated depression been well controlled with lifestyle changes and phar- also may not be candidates.23 macotherapy.12 This article outlines five of the most common procedures, discusses the outcomes and TYPES OF BARIATRIC SURGERY complications of bariatric surgery, and describes the There are currently two major categories of nursing implications for pre- and postoperative pa- bariatric surgery, grouped according to the tient care. predominant mechanism of action: restrictive

In 1998, an estimated 13,365 bariatric procedures were performed in the United States; by 2007, that number had increased to approximately 200,000.

Candidates for surgery. Many people who opt for procedures, such as vertical banded gastro- bariatric surgery have already tried numerous other plasty (VBG) and adjustable gastric banding weight loss strategies, without success. When diet, (AGB); and malabsorptive procedures with exercise, psychotherapy, and pharmacotherapy have a restrictive component, such as Roux-en-Y failed, bariatric surgery has been shown to be an ef- gastric bypass (RYGB), vertical sleeve gastrec- fective treatment for obesity and obesity-related co- tomy (VSG), and biliopancreatic diversion morbidities.13-18 A majority of patients seeking bariatric with duodenal switch (BPD-DS). It’s also not surgery are female (83%), white (60%), and have pri- uncommon for a surgeon to use a combina- vate insurance (78%).19 In one large study, the aver- tion of both restrictive and malabsorptive age age of patients was 42, but adolescents and older procedures. In general, the more complex the adults also undergo bariatric surgical procedures.20 procedure, the better the results in terms of While elective surgery is generally contraindicated weight loss; but there’s evidence that more [email protected] AJN ▼ September 2012 ▼ Vol. 112, No. 9 27 Roux-en-Y gastric bypass. RYGB (often simply called gastric bypass) is the most commonly performed bariatric procedure in the United States, accounting for between 71% and 81% of all bariatric surgeries.19, 25 Open RYGB was first performed in the United States in the 1960s; laparoscopic RYGB was introduced in the early 1990s.26 The surgery, which is irreversible, involves creating a small stomach pouch and attaching it directly to the small intestine using a Y-shaped limb of the small bowel; the larger stomach portion and the duodenum are bypassed. Thus the procedure works both by restricting intake and by slowing the digestion and absorption of food. Although it’s usually performed laparoscopically, open RYGB is still performed in some cases,13, 19, 25, 27 such as in patients who have adhe- sions from previous abdominal surgeries.22 RYGB has been shown to have lower peri- and intraoperative risks than some other procedures24; more research is needed to establish the risks relative to AGB.25, 27

Vertical sleeve gastrectomy. VSG (often simply called sleeve gastrectomy) was originally used as the first step in the BPD-DS procedure, but it’s begin- ning to be used as a stand-alone procedure for bariatric surgery in high-risk patients with severe obesity (BMI of 50 kg/m2 or greater).28, 29 The surgery, which is irreversible, involves removal of 80% to 90% of the stomach, leaving only a gastric “sleeve.”30 The surgery both restricts intake and slows digestion and absorption. Usually performed laparoscopically, this procedure has lower risks of mortality and of major complications compared with RYGB and BPD-DS,28-31 although long-term outcomes need further evaluation.29 Moreover, VSG has been shown to significantly improve or resolve hypertension and diabetes.29, 31, 32

Biliopancreatic diversion with duodenal switch. BPD-DS is usually considered for patients with severe obesity. The surgery, which is irreversible, is a variation on biliopancreatic diversion (the original surgery is now rarely performed). BPD-DS involves removing 65% to 70% of the stomach, leaving the pyloric valve intact. The remaining portion of the stomach is then connected to the proximal portion of the ileum. The surgery both restricts intake and slows digestion and absorption, as digestive enzymes cannot mix with food until food reaches the distal ileum.33 BPD-DS has demonstrated substantial reductions in excess body weight and in the severity of associated comorbidities.34 One study by Iaconelli and colleagues showed a 100% remission rate for type 2 diabetes within one year of surgery.35 The authors also found significant reductions in hypertension, hyperlipidemia, and cardiovascular disease. Four images courtesy of Ethicon Endo-Surgery, Inc. images courtesy Endo-Surgery, of Ethicon Four

28 AJN ▼ September 2012 ▼ Vol. 112, No. 9 ajnonline.com Adjustable gastric banding is the second most common bariatric procedure performed in the United States.19, 25 The procedure, which is restrictive and reversible, was initially devel- oped in the 1980s as an alternative to major surgery.36 A laparoscopic AGB device (the Lap- Band) first won U.S. Food and Drug Adminis- tration (FDA) approval in 2001, and since then its use has increased dramatically; indeed, one source notes that between 2004 and 2007, its use increased from 7% to 23%.14 With a second AGB device (the REALIZE band) receiving FDA approval in 2007, and with AGB considered to be “the safest of the currently available surgical options,” further increases are expected.14 The procedure involves placing an adjustable silicone band around an upper portion of the stomach to form a small pouch, leaving a small stoma to the larger, lower portion of the stomach. Food passes first into the small pouch, where it begins digestion. The digested food then moves through the small stoma into the lower stomach portion and on through the remainder of the gastrointestinal tract. Food intake is restricted by the small pouch capacity; and because of the small stoma size, emptying of food into the lower stomach portion is also delayed. During surgery the band is also connected through tubing to a port placed under the patient’s skin. The tightness of the band can then be adjusted, depending on the patient’s tolerance, by instilling or removing fluid through the port. Adjustments are usually made by the physician on an outpatient basis. Both the band and port are usually placed laparoscopically. The procedure can be done in an ambulatory surgical setting, and patients generally go home within a few hours of surgery.37 The FDA has approved the use of adjustable gastric bands for obese adults ages 18 and older, and is reportedly considering approval for adolescents as young as 14.38 Studies have found the associated mortality rate to be between 0% and 0.1%,14, 39 making it the safest of the available procedures.14 AGB is a good option for obese patients who need bariatric surgery and want to avoid permanent rerouting of the gastrointestinal tract.39

Vertical banded gastroplasty. VBG, some- times called “stomach stapling,” was devel- oped in 1982; it’s a restrictive and reversible procedure. The surgeon first cuts a small hole into the stomach a few inches below the esophagus. Then the surgeon places a line of staples from the hole toward the esophagus to section off a small portion of the upper stomach, creating a small pouch. This pouch is then anchored distally by a prosthetic band. The band slows digestion

Am permission J Gast of 2007;102(11):2571-80 by by allowing smaller-than-normal amounts of food through to the remainder of the gastrointestinal tract. Both the reduced stomach capacity and the delayed emptying give the patient a feeling of early satiety. Rates of mortality and major complications are low.40 Mayo Foundation for Medical Education and Research. All rights reserved. All and Research. Medical Education for Foundation Mayo Reprinted from Decker, GA, et al. GA, et al. Decker, from Reprinted

[email protected] AJN ▼ September 2012 ▼ Vol. 112, No. 9 29 complex procedures also have higher morbidity and studies have shown that bariatric surgery increases mortality rates.24 pulmonary functioning and decreases the severity of asthma and sleep apnea.48-51 Indeed, one study found OUTCOMES that, of 29 obese patients with sleep apnea who used Weight loss. The overall success of a patient’s bariatric continuous positive airway pressure therapy preoper- surgery and the rate and amount of weight lost post- atively, only four required it at two years after bariat- operatively vary based on the patient and the type of ric surgery.50 surgery performed. One study defined success as a loss Cardiovascular disease. Multiple studies have of more than 50% of excess body weight and failure shown an increased risk of coronary heart disease in as a loss of less than 30% of excess body weight at patients who are obese. The Nurses’ Health Study one year after surgery.41 found that the relative risk of coronary heart disease Patients who have undergone BPD-DS have lost an was 3.6 times greater for women with a BMI above average of 80% of their excess body weight at two 29 kg/m2.52 Similarly, the Framingham Heart Study years after surgery, and an average of 70% at eight found that obesity was an important long-term pre- years out.34 Patients who have undergone VSG have dictor of cardiovascular disease.53 The incidence of lost from 59% to 68% of their excess body weight at coronary heart disease in men younger than 50 years 18 months to two years after surgery, respectively.28, 42 was doubled in the heaviest group; among women Patients who have undergone VBG have lost from younger than 50 years, the incidence was 2.4 times 50% to 57% of their excess body weight at one to greater in the heaviest group.

Many people who opt for bariatric surgery have already tried numerous other weight loss strategies, without success.

five years after surgery.40 But it’s important to note Related conditions such as hypertension and hy- that up to 15% of patients have eventually required perlipidemia have been shown to improve in patients revision of their surgery to RYGB or BPD-DS due to who undergo bariatric surgery.17, 18 In one study of weight regain and vomiting.24 Patients who have un- people with severe obesity, 86% of patients with hy- dergone RYGB have lost from 60% to 76% of their perlipidemia and 81% of those with hypertension excess body weight at one or more years after sur- no longer required medications for these conditions gery.15, 43 Patients who have undergone AGB have lost at 12 months after bariatric surgery.17 from 50% to 82% of their excess body weight at one Musculoskeletal problems are common in people or more years after surgery.14, 44 with obesity. Some candidates for bariatric surgery Type 2 diabetes. One of the most encouraging out- will have already undergone surgery to repair or re- comes of bariatric surgery is the reduced severity and place weight-bearing joints. Weight loss reduces the even the elimination of type 2 diabetes.15, 24 Overall, re- strain on the body’s muscles and weight-bearing joints, mission has been seen in 50% to 85% of all patients thus easing joint and muscle pain. Weight loss result- who have undergone bariatric surgery, although re- ing from bariatric surgery has also been shown to im- mission is “less likely” in older patients and in those prove the severity of lower back pain and to improve who have had type 2 diabetes for a longer period of overall functionality.16 time.12 One study by Wool and colleagues even reported remission rates of 87% to 90%.22 Remission COMPLICATIONS rates have been highest in patients who underwent Bariatric surgery, like other surgeries, carries some risk either biliopancreatic diversion or BPD-DS, followed of complications. A study by Cawley and colleagues by RYGB, then laparoscopic AGB and VBG.12 Studies found that preexisting obesity-related comorbidities have found that 72% to 81% of patients with type 2 were significantly associated with the likelihood of de- diabetes have been able to stop using diabetes medi- veloping certain complications after bariatric surgery.54 cations at one year follow-up.17, 18 The two comorbidities most predictive of postop Sleep apnea, asthma, and other respiratory prob- erative complications were sleep apnea and gastro- lems are frequently seen in people who are obese.45, 46 esophageal reflux disease; others included diabetes, The loss of abdominal and intrathoracic fat reduces hyperlipidemia, and hypertension. restriction of the lower airway, while the loss of ex- ‘Dumping’ syndrome, a common complication, cess fat around the neck reduces obstruction of the refers to a group of symptoms that can occur when upper airway, thus enhancing breathing.47 Several calorically dense carbohydrates are ingested and

30 AJN ▼ September 2012 ▼ Vol. 112, No. 9 ajnonline.com inferior vena cava filter.65, 67 Compression stockings Terms Defined2 and pneumatic sequential compression devices are also frequently ordered for deep vein thrombosis Overweight is defined as a body mass index prophylaxis.65 (BMI) of 25 to 29.9 kg/m2. Anastomotic leak. Postoperative leaking at the anastomotic sites in RYGB, BPD-DS, and VSG is 2 Obesity is defined as a BMI of 30 kg/m or greater. a serious complication that can be life threatening. Three subcategories of obesity are also recognized: Anastomotic leak has been reported in 0.12% to 2 •• Class I: a BMI of 30 to 34.9 kg/m . 20% of patients undergoing open or laparoscopic 2 •• Class II: a BMI of 35 to 39.9 kg/m . RYGB.13, 28, 42, 66, 68 The signs and symptoms of anasto- 2 •• Class III: a BMI of 40 kg/m or greater. motic leak can be subtle or absent; they include abdominal pain, nausea and vomiting, tachycardia, fever, hypotension, and oliguria.66 Some physicians may order a swallowing study when the stomach “rapidly and without regulation to evaluate for leaks on postoperative day 1 or 2.66 empties its contents into the small intestine.”55 Symp- Snyder and colleagues have reported that robotic- toms, which can arise 15 minutes to two hours after assisted RYGB resulted in fewer anastomotic leaks eating and generally last about 30 minutes, may in- and other major complications, compared with lap- clude tachycardia, dizziness, sweating, nausea, vomit- aroscopic RYGB; hospital stays were also shortened.69 ing, bloating, abdominal cramping, and diarrhea.33, 55 Death. Although bariatric surgery is generally safe, Patients should be instructed which foods to avoid in there is always a risk of death. Overall, death occurs order to avoid this complication. Dumping syndrome in 0.15% to 0.64% of patients who undergo bariatric occurs more often with RYGB than with BPD-DS, surgery.13, 19, 70, 71 Mortality rates vary somewhat by sur- probably because the latter procedure preserves more gery type. For patients who undergo VBG, it’s approx- of the stomach, including the pyloric valve.34 Patients imately 1.6%.24 Among patients who have undergone who undergo laparoscopic RYGB,56 and patients who either traditional biliopancreatic diversion or BPD-DS, have preexisting hyperlipidemia or gastroesophageal the mortality rate is approximately 1.2%.24 Frezza reflux disease appear to be at especially high risk for and colleagues have noted that VSG has a mortality dumping syndrome.54 rate of 0.5%.42 The mortality rate for the adjustable Cholelithiasis. The development of gallstones is gastric band is approximately 0% to 0.1%.14, 39 A a complication related to postoperative weight loss meta-analysis found that, among patients undergoing rather than the surgery itself. However, since choleli- RYGB, mortality rates were 0.44% and 0.16% for thiasis occurs in about one-third of patients who un- open and laparoscopic procedures, respectively.72 dergo bariatric surgery, it deserves mention.57 Both obesity and rapid weight loss increase a patient’s propensity to develop gallstones, especially among women.57-59 Studies indicate that 22% to 45% of pa- Although bariatric surgery tients who undergo bariatric surgery will develop gallstones within the first few months after surgery.58-61 In is generally safe, there is earlier years, it wasn’t uncommon for a prophylactic cholecystectomy to be performed along with bariatric always a risk of death. surgery; with the advent of laparoscopic bariatric surgery, this is no longer recommended. Moreover, studies have also shown that in many cases the gallstones resolve on their own59; the off-label, prophylactic ad- The top three causes of death in people who un- ministration of ursodiol has also been shown to help dergo bariatric surgery are pulmonary embolism prevent gallstone formation.62, 63 (15% to 32%), cardiac complications or arrest (13% Pulmonary embolism and deep vein thrombosis. to 18%), and sepsis (18%).19, 71 Other causes of death Patients who undergo bariatric surgery are at higher can include anastomotic leak (15%), gastrointestinal risk for deep vein thrombosis and pulmonary em- bleeding or hemorrhage (8%), bypass obstruction bolism.64 As a result, physicians often recommend (5%), and small bowel obstruction (3%).71 early and frequent ambulation following surgery.65 Complications unique to AGB. Although this pro- Some physicians may order the administration of cedure presents with far fewer risks than other bar- low-molecular-weight or low-dose heparin after iatric procedures,14 unique complications can occur.27 surgery.65, 66 For patients who are at very high risk Among the most common are port disconnections or for pulmonary embolism, deep vein thrombosis, or rupture, port displacement, and stomach slippage stroke, some physicians may opt to place a temporary with pouch dilatation73, 74; others include band rupture, [email protected] AJN ▼ September 2012 ▼ Vol. 112, No. 9 31 band erosion, port blockage, port infection, and should know that the use of a patient-controlled anal- tubing-related malfunctions.14, 73-75 Studies have found gesia pump after surgery is common,13 and that they that 12% to 20% of patients require additional sur- may be prescribed additional analgesics as needed for gery within one to 12 years after AGB.73, 76, 77 In the breakthrough pain.33 Antiemetics may also be pre- event of minor complications, the band can be de- scribed. The importance of early and frequent ambu- flated or removed if necessary. If major complications lation in preventing deep vein thrombosis, pulmonary arise, further surgery may be required. embolism, bowel obstruction, atelectasis, pneumonia, skin breakdown, and even discomfort should be ex- NURSING IMPLICATIONS plained.79-81 Preoperative evaluation and patient teaching. As be- It’s also important to discuss realistic goals for fore any surgery, the nurse must obtain a thorough weight loss with patients prior to surgery. Many pa- history, perform a physical assessment, and obtain tients have unrealistic ideas about what bariatric sur- baseline vital signs. For patients considering bariatric gery can do. Some may expect to lose nearly 100% surgery, comprehensive preoperative evaluation by of their excess body weight; indeed, one study found a psychiatrist or psychologist may also be indicated, that patients’ average “dream” weight (“a weight or the patient’s insurer may require it. In a consensus you would choose if you could weigh whatever you statement, the American Society for Bariatric Surgery wanted”) was equivalent to 89% ± 8% of their ex- (now known as the American Society for Metabolic cess body weight loss—about 40% higher than what and Bariatric Surgery) noted that such evaluation most bariatric surgeons consider to be a successful “is not routinely needed, but should be available if outcome.82 Another study found that women, whites, indicated.”78 The purpose is to help identify psycho- and patients with higher preoperative BMIs were logical factors that might disqualify a patient from more likely to have unrealistic expectations of bar- or delay surgery, such as untreated depression or a iatric surgery.83 Patients whose expectations are un- lack of understanding about the risks of surgery and realistic are more likely to be nonadherent to the the necessary postoperative regimen.23 postoperative plan of care,84 and thus are at higher It’s essential for nurses to be aware of their own risk for regaining weight. attitudes and behaviors regarding obesity and bariat- Patients must be able to identify healthy behaviors ric surgery. Many people who are obese have been that lead to successful weight loss. For example, one the victims of discrimination and abuse.33 They may study found that attending postoperative support feel ashamed or embarrassed that they’ve been un- group meetings, being able to control food urges, able to lose weight by other means and thus require being more physically active, and following up with surgery. Some may have fears about the operation it- a physician were all significant factors in successful self or about how life might change afterward; some weight loss.85 Both before and after bariatric surgery, may worry that even after surgery, they’ll fail to lose then, patients should be encouraged to participate in weight. Nurses need to be able to support a patient’s support groups and individual counseling for help in decision to have surgery, acknowledge the patient’s learning and implementing relevant coping and life- fears, and strive to maintain the patient’s dignity. style management techniques.85 Lastly, patients should be prepared for certain aes- thetic changes. Rapid weight loss following bariatric surgery can result in an excess of stretched skin, which It’s important to discuss can cause both physical and mental discomfort. Sur- gical removal of this skin is usually the only option. realistic goals for weight loss Such surgery can be risky; in particular, abdominoplasty has a rate of complications as high as 50%.86 with patients prior to surgery. Most insurance companies will not cover surgery to remove excess skin unless the skin causes significant obstruction to movement or frequent infections of the skin folds occur. Patients should be informed that Help patients know what to expect. It’s important the denial rate for such surgeries is reportedly 40% to explain to patients beforehand what to expect to 50%.87 But it’s also worth noting that a majority upon awakening from surgery. This will likely include of patients who undergo abdominoplasty after bar- receiving iv fluids and having in place a urinary cathe- iatric surgery report an improved quality of life.88 ter, pneumatic sequential compression devices, and Postoperative assessment and patient teaching. antiembolism compression stockings.33 The patient As with any surgery, vital signs must be monitored may also have a nasogastric tube, or a wound drain closely for the first few hours after the procedure and at the incision site. Methods of postoperative pain at regular intervals thereafter. The following are con- control should be discussed before surgery. Patients cerns specific to bariatric surgery.

32 AJN ▼ September 2012 ▼ Vol. 112, No. 9 ajnonline.com Respiratory function. Patients who undergo bariat- sliding-scale insulin regimen after surgery for the ric surgery are at risk for postoperative respiratory treatment of hyperglycemia. Hypoglycemia is also complications, as intrathoracic and abdominal fat can common after bariatric surgery. Recognition and restrict lung expansion and decrease reserve volumes. treatment of hypoglycemia must be swift. Many Respiratory complications can also occur as a result physicians will order glucose iv or glucagon im be- of anesthesia or the use of opioids for postoperative cause patients are typically on npo orders, and to pain management. Respiratory function should be as- avoid dumping syndrome, which can occur with sessed periodically using pulse oximetry; some patients oral ingestion of glucose gel or juice. may require continuous monitoring. Encouraging Nutrition and hydration. After bariatric surgery, cough and deep breathing is essential to preventing at- patients are kept on npo pending evaluation with a electasis and pneumonia. Some physicians may order Gastrografin swallow study or an abdominal X-ray; the use of incentive spirometry devices, although their these tests are performed to rule out anastomotic therapeutic efficacy is still under scrutiny.89-91 leak and gastric dilatation or obstruction, usually on

Because intake capacity has been reduced to as little as 15 to 30 mL after surgery, the nurse should explain the importance of taking small sips of fluid to reduce nausea and vomiting.

Skin care. Because their weight puts excess pressure postoperative day 1.13, 66, 92 Patients are kept hydrated on boney prominences, patients who are obese are with iv solutions. Once patients are cleared by the more likely to develop pressure ulcers. Frequent re- evaluation, most can begin to take fluids orally, be- positioning and ambulation should be encouraged. ginning with water, then clear liquids, then full liquids Special mattresses or inflatable mattress overlays may as tolerated. Because intake capacity has been dras- be used to prevent pressure ulcers. Patients who are tically reduced to as little as 15 to 30 mL,92 the nurse obese are also more likely to develop yeast infections should explain the importance of taking small sips in under skin folds. These areas must be kept clean and order to reduce nausea and vomiting. Fluids should dry; if a patient does develop a yeast infection, anti- be sugar free, caffeine free, and noncarbonated. High- fungal creams may be applied. Careful inspection and protein supplements or shakes may also be prescribed. care of incisions are critical as well. If the surgeon has Once the patient is able to tolerate oral fluids, iv hy- placed a drain, monitoring the amount and type of dration can be discontinued. Strict management of drainage should be done at least once per shift.33 intake and close monitoring of urine output are essen- Warmth, redness, pain, and drainage at the incision tial for determining fluid volume status.33 Advance- site can indicate infection and should be reported. ment of the patient’s diet from liquids to solids will Patients should be instructed on how to splint their vary. Generally, patients consume a liquid diet for a incisions during coughing and movement in order to few weeks after surgery and then progress to a low- prevent dehiscence.33 fat, low-carbohydrate, high-protein diet. Concentrated Abdomen and bowel sounds. Abdominal rigidity sweets and carbonated beverages should be avoided. or pain, absent bowel sounds, lack of flatus, lack of Nutritional deficiencies are common after bariatric bowel movements, nausea, or a combination of these surgery, and patients are often prescribed a multivita- can indicate possible bowel obstruction and warrant min regimen. One study found that, among patients immediate attention. Postoperative nausea and vom- who had undergone RYGB, more than half were defi- iting must also be managed. For example, vomiting cient in vitamin B12, vitamin D3, beta carotene, and after AGB can cause band slippage, which may re- hemoglobin, and more than one-quarter were defi- quire reoperation. Patients are often prescribed anti- cient in zinc, ferritin, magnesium, and iron.93 Protein emetics and proton pump inhibitors after surgery as deficiency is also common after bariatric surgery.94 a preventive measure.66 Supplemental protein has been shown to help patients Blood glucose levels must be monitored closely in reach their daily protein intake goal.94 patients with diabetes or who are on npo orders (pa- Patients at risk for dumping syndrome will need tients who have bariatric surgery are kept on npo [non instruction regarding how and what to eat to prevent per os, or nothing by mouth] at least on postoperative this complication. Recommendations include eating day 1). Patients with diabetes may be placed on a five or six smaller meals rather than three large ones; [email protected] AJN ▼ September 2012 ▼ Vol. 112, No. 9 33 eating slowly and chewing well; avoiding fluids with Lauren E. Gagnon is a nurse on the cardiovascular surgical unit meals; and avoiding fried foods and foods high in fat at Catholic Medical Center in Manchester, NH, where Emily J. or sugar content.95 Karwacki Sheff is the nursing practice and standards coordina- The postoperative regimen. Several studies have tor. Karwacki Sheff is also a clinical instructor in the School of Nursing at MGH Institute of Health Professions in Boston. Con- shown that adherence to postoperative recommenda- tact author: Emily J. Karwacki Sheff, [email protected]. The tions and attendance at follow-up visits and support authors have disclosed no potential conflicts of interest, financial groups are associated with more successful weight or otherwise. loss after surgery.96-98 Among patients who fail to achieve their weight loss goals, nonadherence to the REFERENCES postoperative plan of care is often a major factor. 1. Flegal KM, et al. Prevalence and trends in obesity among US adults, 1999-2008. JAMA 2010;303(3):235-41. One study found that frequent snacking, not exercis- 2. National Heart, Lung, and Blood Institute (NHLBI) Obesity ing, and not attending support groups were the most Education Initiative Expert Panel on the Identification, Eval frequently cited areas of nonadherence to postoper- uation, and Treatment of Overweight and Obesity in Adults. ative recommendations.99 Another study identified Clinical guidelines on the identification, evaluation, and several factors associated with nonadherence, includ- treatment of overweight and obesity in adults: the evidence report. Bethesda, MD: National Institutes of Health; 1998 ing emotionally triggered eating or “grazing,” impul- Sep. http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns. sivity, binge eating, and having a “primary affective pdf. 84 disorder.” Similarly, binge eating tendencies, low 3. National Heart, Lung, and Blood Institute (NHLBI). What self esteem, physical inactivity, and a lack of social are the health risks of overweight and obesity? National support have been associated with lower chances of Institutes of Health. 2010. https://www.nhlbi.nih.gov/health/ postoperative success in losing or maintaining weight health-topics/topics/obe/risks.html. 85, 100 4. Weight-control Information Network. Do you know the loss. health risks of being overweight? National Institute of Dia Extensive teaching regarding diet, physical activity, betes and Digestive and Kidney Diseases, National Institutes and lifestyle is vital in helping patients to make the of Health. 2007. http://win.niddk.nih.gov/publications/ necessary changes, achieve and maintain weight loss, health_risks.htm. and adjust to life after surgery. Indications that a pa- 5. Gortmaker SL, et al. Social and economic consequences of tient might be nonadherent to the postoperative plan overweight in adolescence and young adulthood. N Engl J Med 1993;329(14):1008-12. of care include a history of binge eating, a history of 6. Rand CS, Macgregor AM. Morbidly obese patients’ per- mood or anxiety disorders, missing preoperative ceptions of social discrimination before and after surgery appointments, and nonadherence to preoperative for obesity. South Med J 1990;83(12):1390-5. recommendations for weight loss and exercise.98, 101 7. Ashmore JA, et al. Weight-based stigmatization, psycho Although it’s ultimately up to each patient to follow logical distress, and binge eating behavior among obese her or his plan of care, nurses should address any of treatment-seeking adults. Eat Behav 2008;9(2):203-9. these warning signs and discuss possible solutions 8. Maddi SR, et al. Reduction in psychopathology following bariatric surgery for morbid obesity. Obes Surg 2001;11(6): with the patient. 680-5. Discharge teaching should include verbal and writ- 9. Schowalter M, et al. Changes in depression following gas- ten instructions about the dietary progression; the tric banding: a 5- to 7-year prospective study. Obes Surg medication regimen; incision care; signs and symp- 2008;18(3):314-20. toms that must be reported to the physician; follow- 10. Mechanick JI, et al. American Association of Clinical Endo up appointments (including those with the patient’s crinologists, the Obesity Society, and American Society for surgeon, primary care provider, and nutrition coun- Metabolic and Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and selor); contact information for postoperative support nonsurgical support of the bariatric surgery patient. Endocr groups; and any restrictions on driving and other ac- Pract 2008;14 Suppl 1:1-83. tivities. The nurse should ensure that the patient un- 11. Snow V, et al. Pharmacologic and surgical management of derstands the importance of periodic assessment for obesity in primary care: a clinical practice guideline from nutritional deficits. One study found that, during the the American College of Physicians. Ann Intern Med 2005; 142(7):525-31. first postoperative year, some patients demonstrated 12. Dixon JB. Obesity and diabetes: the impact of bariatric an inadequate intake of nutrients such as protein, cal- surgery on type-2 diabetes. World J Surg 2009;33(10): cium, and iron.102 The value of regular physical activ- 2014-21. ity and participation in support groups should also 13. Agaba EA, et al. Laparoscopic vs open gastric bypass in be reiterated. ▼ the management of morbid obesity: a 7-year retrospective study of 1,364 patients from a single center. Obes Surg 2008;18(11):1359-63. 14. Favretti F, et al. The gastric band: first-choice procedure For 79 additional continuing nursing education for obesity surgery. World J Surg 2009;33(10):2039-48. articles on surgical topics, go to www.nursingcenter. 15. Levy P, et al. The comparative effects of bariatric surgery com/ce. on weight and type 2 diabetes. Obes Surg 2007;17(9): 1248-56.

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