Med-Surg Topic of the Week .... Let's go back to Bariatrics

talaxandra · Oct 31, 2004

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/

wonderbee, BSN, RN · Oct 31, 2004

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

RNPATL, DNP, RN · Oct 31, 2004

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 · Oct 31, 2004

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, BSN, RN · Nov 2, 2004

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 · Nov 2, 2004

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, BSN, RN · Nov 3, 2004

Thanks!

RNPATL, DNP, RN · Nov 6, 2004

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, DNP, RN · Nov 6, 2004

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.

talaxandra · Nov 6, 2004

Patrick, I agree with you that there is strong evidence that very high BMI is strongly correlated with reduced life expectancy and a significantly higher incidence of those disease which are associated with obesity (joint deterioration, diabetes, hypercholesteremia, hyperlipidaemia, hypertension etc). Inicdentally, there is no condition which fat people get that thin people do not get.

My point, which I probably didn't articulate clearly, is that there are no studies on fat populations who have not been on the diet treadmill, and thus yo-yoed, a condition which is shown to contribute to increased mortality and morbidity (increased incidences of heart disease, metabolic impact etc). There are also no studies which clearly demonstrate that formerly fat people who permanently lose weight have improved mortality rates, compared with fat people who exercise (which has been demonstrated to lower BP, improve blood sugar control etc).

Fat patients who present to GPs are more likely to have their weight adressed than their presenting problem, regardless of how potentially serious that problem is. In the last couple of years alone I have looked after patients who had fatigue (renal failure), shortness of breath (pneumonia), increasing abdominal girth and breathlessness (acites), and dizziness (accoustic neuroma) that were initially diagnosed as being related to obesity.

Fat patients with lipema are often advised to lose weight, even though this has no affect on the condition or symptomology.

One woman has written of her experience with a breast lump - her doctor spent almost the entire first appointment talking about her weight; on the followup, following biopsy, she once again talked about how the patient had to do something about her weight. It took the patient actually saying "What I want to know is do I have breast cancer?" To which the doctor replied "No, you don't. Do you want to do something about your weight or not?"

My former GP ignored my PR bleeding, but sent me off for thyroid function tests (in the absence of any symptoms of hypthyroidism). She also didn't have a BP cuff big enough for my arm, and diagnosed me with hypertension (145/95) - she was preparing to write me a script for antihypertensives when I stopped her and asked her to find a larger cuff. Turns out my BP was 108/70. My arm circumference is only 39cm/15" - hardly gargantuan. As I'm sure you know, a one-off reading is rarely enough to disgnose hypertension, and I can only put her reaction down to an assumption that, as I am fat, I would be hypertensive.

That bariatric surgery is risky is clear - and it may very well be that this risk is balanced by gains for some morbidly obese patients. It sounds as though your institute screens potential patients exceptionally well, and should be congratulated for that. However, it is undeniably true that this is not universally the case. It is also true that some patients skew their symptoms, or even invent symptoms, to qualify (there's a thread here where a member was advised to invent TIA symptoms to qualify for WLS when her physician advised that she didn't need it).

RNPATL, DNP, RN · Nov 6, 2004

Excellent response. You articulate very well and it is a pleasure to read your responses. I totally agree with you. It is really is sad that in our society today, physicians and other members of the health care team disregard the symptoms of a patient and focus most of their energy on weight. I was saddened to read your story about the woman with the breast biopsy.

It is a fact that medicine is not what it use to be. Patients are merely a number or a Medicare/Insurance diagnosis code. For most people, if they do not control their health care and guide the process, they are often lost within the system. This has been my personal experience. Many times I have been thankful that I am an RN and I can negotiate the health care maze. In addition, physicians that become obssessed with one aspect of a patient's health status (i.e. being overweight) and do not holistically focus on the patient, do not deserve to be in practice. Furthermore, to make a patient suffer much like your story had indicated, is simply wrong.

In relationship to studies, I totally agree with you and in fact, watched a Dateline NBC program last night that mirrored your comments. There simply is not enough study information available about whether people who were formerly fat are better off health wise.

I am hoping that as we move into the future, there will be more information available so patients can make an informed and educated decision for themselves. There is much more excitment about the WLS than realism with it. WLS has almost become a religion for those people that have had success. But, there are risks!

Thanks again for your great response. :)