[RNPATL]

I just came back from a great conference on bariatric surgery. We have recently started our program and the seminars were wonderful. I think the most compelling and touching part of the program were the testimonials by some of the presenters ..... this was totally unexpected as these women looked wonderful ....wonderful!

I came away from this seminar with a renewed desire to be a big part of this program. It is truly life changing for those patients that have the surgery. It can be high risk for the severely obese, but in the long run, sometimes I think the benefits really can outweight the risks.

Each of the women that presented had their own story. Some shared how they grew up and were always very heavy .... others shared about their pain and profound sadness at the rude and hateful things people would say to them. Most, if not all had terrible memories from their days in high school. Each had their own person reasons for having the surgery. One lady said that if her insurance did not pay for it, she would mortgage her house and do whatever else she needed to do to secure financing so she could get the sugery done .... it was worth everything to her ... she had lost over 300 pounds and looked amazing! The other presenters talked about how insurance companies are starting to change their perspective on bariatric surgery. Mostly because co-morbities are more expensive .... getting bariatric surgery actually can save the insurance company money!

Interesting to point out is that many of the people that get bariatric surgery are disabled because of their weight. Once the weight comes off, their physical condition improves and they can get back to work and come off of disability, but many are afraid .... they require increased psych counseling as well as transitional adjustment therapy so they can re-enter life as a normal weight person. I find these issues amazing, but the reality is, most severely obese people become hermits and hide away. Once the weight comes off, some do struggle with getting back into the swing of life. The presenters encouraged programs to develop an enhanced therapy and psych screening prior to approving a patient for surgery.

Just thought I would share this with you and welcome your comments and feedback. I feel great about being a part of a program that changes peoples lives like this does.

[talaxandra]

Hi Patrick
what kind of information did you get about long-term complications and mortality? I'm interested because Iowa Methodist Medical Center in Des Moines has just shut down its bariatric program (8 deaths out of 233 surgeries) and, as I'm sure you know, American insurances programs are sharply cutting down on funding for these operations.
For anyone who's interested in getting a balanced view (positive and negative commentary, from surgeons, medical professionals, pateints and families) take a look at http://gastricbypass.netfirms.com/

[RNKittyKat]

Patrick, did you come away with a sense of contraindications to bariatric surgery?

[RNPATL]

No - I actually came away from the seminar with a sense of hope for those people that are obese and have tried everything. Yes, I agree that there are risks and the fact that it is an elective surgery makes the risks that much more real. But for severely obese people, they do not view gastric bypass as an elective surgery ... they view it as very necessary for their life.

Unfortuantely, during the seminar, we learned about the history of gastric bypass and the number of deaths. The surgery has improved a great deal since those days, but there are still clear risks to having the surgery. In my program, we deal mainly with the high risk patients. I can be very scarey for these folks, but the nurses need to be aware of s/s of significant change and proactively respond to these changes so the patients clinical needs can be communicated and addressed by the physician.

There is no doubt that any kind os surgical intervention is risky, but for some people, the risk of surgery does not outweight the benefits of it.

[talaxandra]

I guess the thing that concerns me most is that, 40 years after the first bariatric surgery, there are still no long-term studies published. No morbitity stats, no firm mortality figures, nothing. We don't even have compelling evidence that being fat (vs dieting, yo-yoing weight, and the known adverse health impact of being a member of a marginalised group) causes the problems associated with high BMI.

[meownsmile]

We are getting ready fairly soon to start doing the bariatric surgeries in our hospital. Im still a little hesitant because of the staffing they give us now for new general surgicals. Thats still to be determined i guess if it will work out or if they will adjust staffing ratios.
But on another side,, a question. Were some of the morbidity caused by the bariatric surgeries due to the patient not following the protocol regarding supplements they need after the surgery? And if so how is that related to care given in the hospitals? Just asking,, because if there is a different approach to teaching with these patients to prevent deaths, what would be some of the more important aspects of teaching to impress on the patient?

[talaxandra]

It's difficult to assess moridity factors, as there is so little done in terms of published follow-up (some studies have discounted over 50% of bariatric surgery patients, or accounted for them as "lost to follow up" without further explanation).
Depending on the surgery and the surgeon, post-op mortality rates are between 0.5 and 2% in the first few days, with some estimates of mortality at day 30 as high as 8%.
While I'm sure that non-adherence to post-op routine cannot be wholly dismissed, the idea (which I am not attributing to you, meownsmile ) that M+M issues are caused by patient noncompliance is at best dubious. Considering what bariatric patients go through, their strong desire to lose weight, and what they need to do to qualify - at least in theory - they tend to be more compliant than the average surgical patient. This idea is underpinned by the assumption that fat people lack control, and therefore won't follow the restricted postop regime.
The impression I get from weight-loss surgery survivor pages is that mortality and morbidity is often related to surgical complications - leaking anastamoses, wound breakdown, adhesions, the need for further surgery (revision, cholecystectomy, reversal), impair immunity, and malnutrition. Particularly in the more radical surgeries, it doesn't matter how many supplements you take if you don't have enough digestive tract to absorb effectively. That said, I understand lap banding is less likely to cause these kinds of complications. On the other hand, it's still pretty new, so who knows.
Many patients are not told that surgeons expect weight to stabilise a year or so after the surgery - a 50% rebound of weight after the initial large loss - regardless of compliance. It may be possible that some long-term mortality arises from such patients further restricting their caloric intake.

[meownsmile]

Thanks!

[RNPATL]

Originally Posted by meownsmile

We are getting ready fairly soon to start doing the bariatric surgeries in our hospital. Im still a little hesitant because of the staffing they give us now for new general surgicals. Thats still to be determined i guess if it will work out or if they will adjust staffing ratios.
But on another side,, a question. Were some of the morbidity caused by the bariatric surgeries due to the patient not following the protocol regarding supplements they need after the surgery? And if so how is that related to care given in the hospitals? Just asking,, because if there is a different approach to teaching with these patients to prevent deaths, what would be some of the more important aspects of teaching to impress on the patient?

Staffing can be a factor for the post-op bariatric patient. We currently send our immediate post ops to ICU for the first 18 hours. Once they pass their gastrograffin, they are transferred to the surgical step down unit for the remainder of their stay. We staff our program with a nurse to patient ratio of 1:4-5.

In relationship to you question regarding M&M .... there are many studies that have been done on both the high risk surgical (i.e. those with a BMI >40) as well as the lower risk patients. All of our patients are open procedures and we are planning on adding the lap. procedure in the future. So far, our program has handled over 125 patients ... all of which were considered high risk. Our stats are very good. I have to agree with the previous poster in that these results are really dependent upon the surgeon as well as techiques used during surgery. As far as post operative recovery after leaving the hospital, the patient plays a very active role.

Most successful bariatric programs have an intense pre-screening program. Consults for Nutrition, GI, Cardiology, Endocrine, Psych, etc are not uncommon and in fact, with our program are mandatory. Any of the these consulting physicians can place a hold on the patient. If and when the patient passes the consults and they are ready for the surgery, our doc requires that the patient signs a contract with the patient for their post-op care as well as follow-up for a full 18 months. The patient receives extensive post-op instructions and teaching from the nurses, physician as well as nutritional staff after they are on the surgical step-down unit and up until they discharge from the hospital.

During the initial recovery phase, after they have left the hospital, the patient is generally armed with a great deal of teaching to help through the roughest part of their recovery. Patients are required to return to their surgeon's office for counseling with a therapist to help them deal with the emotional effects of their surgery. Most patients have reported a significant loss in that they can not eat to satisfy their emoitional needs.

It is pretty hard for a patient to really eat themselves to death after the surgery. If they overeat, they puke ... pretty simple. If they eat sweets initially, they develop dumping syndrome. These are miserable side effects that most patients try to avoid.

As far as weight gain .... most patients lose the majority of their weight at the 18-24 month mark. By this time, they have learned what they can and can not eat and they have also learned that their new pouch has expanded a little and they can eat more than they could directly after the surgery. I have not yet seen an patient come back with a weight gain. I agree that there are not great studies out there to help us understand the long term effects of WLS, but gastric bypass has been around for a number of years.

One last note .... after our patients go through their RNY procedure and to combat the protein loss, our surgeon places a gastric tube into the original stomach and provides protein feedings to the patient during the immediate post-operative period. This does help with the protein loss and provides the patient with the nutrition they need to help them heal during this period. We have found that this intervention alone has really made a huge difference in the patient's post operative recovery.

Hope some of this information helps.

[RNPATL]

Originally Posted by talaxandra

I guess the thing that concerns me most is that, 40 years after the first bariatric surgery, there are still no long-term studies published. No morbitity stats, no firm mortality figures, nothing. We don't even have compelling evidence that being fat (vs dieting, yo-yoing weight, and the known adverse health impact of being a member of a marginalised group) causes the problems associated with high BMI.

I have to say that I really disagree with this statement. There is certainly compelling information and studies available on the long term effects of mobid obesity and increased BMI. I do agree that there are very few long term studies completed on the gastric bypass patients. Given the popularity of WLS, I am sure more long term studies will be done and perhaps available in the near future.

I think that people considering WLS, need to do some information searches and look at both sides. Certainly, for people that have a BMI that would merit WLS, it a viable option. However, there are great success stories and there are real tragic stories. This is not a surgery that one should enter into without good education and strong knowledge. In addition, the choice of a physician is critical to the very best overall outcomes, as well as the hospital they patient will recover in. There are very clear s/s that nurses need to monitor their patients for.