Transcript Preoperative evaluation of the Bariatric patient.
Preoperative evaluation of the Bariatric patient.
William Bakhos,MD
Preoperative Focus
Multidirectional
Concomitant patient education
Informed consent
Medical evaluation for risk assessment
Strategies for risk reduction
Patient Education Content
Health risks and medical hazards associated with obesity.
Quality of life issues.
Low probability of success with dietary or other non-surgical weight control programs.
Weight loss results of surgery, including failure rates of the different types of procedures Impact of weight loss.
Necessity for long-term follow-up.
Patient Education Content
Possible complications
Mechanisms for weight loss
Post-operative alcohol restriction
Available and accepted operations for obesity treatment,results,advantages,disadvantages, operative risks and complications
Mortality rate (broken down by BMI and severe medical problems)
Contraindications to Surgery
High medical risk.
Unable to understand the operation.
Unrealistic expectations.
Unresolved emotional illness.
Drug abuse/alcoholism.
Unwilling to sign follow-up contract.
Does not have a support person.
Initial Screening
H&P- Medical and Surgical History
Family History/Social History
Medications/Allergies
Diet History
Physical Exam- HT, WT, BMI, VS
Initial Screening
Labs
Chemistry, liver function, renal function
Lipid Profile
CBC
Iron Profile- TIBC, total iron, saturation
B-1, B-12 levels
HbA1c
H-Pylori
Drug Screen (optional)
Initial Screening Radiology
U/S liver/GB
CXR UGI Swallow Study (optional) Cardiac
EKG Venous Doppler Studies (optional)
Preoperative Evaluations ASBS and SAGES Guidelines For Surgical Treatment –Bariatric Surgery, Published in 2000:
The multidisciplinary approach includes Medical management of comorbidities
Dietary instruction, Exercise training,
Specialized nursing care and psychological assistance as needed.
Having a multidisciplinary team who can address these necessary components of bariatric patients’ needs is imperative.
Preoperative Behavior Change
Preoperative exercise program.
Patients sometimes asked to maintain body weight or lose weight prior to surgery.
Patients asked to quit smoking prior to surgery.
Reduces risk, establishes healthy habits,and tests motivaiton and commitment.
Dietary Evaluation Registered Dietitian
Address dietary concerns and begin making changes now
Avoid the Last Supper Syndrome
Diabetes Education
Exercise Evaluation
Preoperative exercise program.
Assessment .
Mobility Issues.
Physical Conditioning.
Education.
Motivation.
Gastro-Intestinal Evaluation.
Endoscopy.
Ulcers (Helicobacter pylori).
Esophageal Disorders.
Irritable Bowel Syndrome.
Crohn’s Disease.
Birth control counseling.
Absence of pregnancy.
Birth control.
Risky pregnancy in the early post-op. period (1-2 years).
Weight loss may improve fertility.
Cardiac Risk & Complication Rate
One point assigned per risk factor : 1- CAD 2- CHF 3- CVD 4- High-risk surgery 5- Diabetic requiring insulin 6- Pre-op creatinine >2.0 mg/dl
Risk Class/ complication rate Class I Zero 0.4% Class II One 0.9% Class III Two 6.6% Class IV Three 11.0%
Lee TH, et al. Circulation . 1999;100:1043-49
Cardiac Risk Assessment.
Stress Testing
Echocardiogram
Medication adjustment
Cardiac Clearance
Beta Blockade
Major criteria Use Beta-blockers in patients meeting any of the following criteria
History of MI,current angina Or use of sublingual nitroglycerine Positive exercise test results Q waves on ECG Patients who have undergone PTCA or CABG and who have chest pain History of TIA or CVA Diabetes mellitus requiring insulin therapy Chronic renal insufficiency, defined as a baseline creatinine level of at least 2.0 mg/dL (177 µmol/L) Lee TH et al.
Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery.
Circulation.
1999;100:1043-1049 .
Beta Blockade
Minor Criteria
Use Beta -blockers in patients meeting any 2 of the following criteria: Aged 65 years or older Hypertension Current smoker Serum cholesterol concentration at least 240 mg/dL (6.2 mmol/L) Diabetes mellitus not requiring insulin therapy Mangano et al.
Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery: Multicenter Study of Perioperative Ischemia Research Group.
N Engl J Med.
1996;335:1713-1720.
Pulmonary Evaluation.
Obstructive Sleep Apnea (testing and treatment).
Asthma.
Smokers.
Endocrine Evaluation
Diabetes Management.
Diabetes Education.
Thyroid disease.
DVT Prophylaxis
Early ambulation
Elastic stockings Intermittent pneumatic compression devices – IPC
Inferior vena caval filters
Low Dose Unfractionated Heparin
Low Molecular Weight Heparin (LMWH)
IVC Filter placement
Preoperative vena caval filter placement should be considered in bariatric patients with Prior pulmonary embolus Prior deep venous thrombosis Evidence of venous stasis Known hypercoagulable state.
Keeling WB et al
..Current indications for preoperative inferior vena cava filter insertion in patients undergoing surgery for morbid obesity. Obes Surg. 2005 Aug;15(7):1009-12
Pre-Operative Visit
Physical Exam.
Changes to medications, condition, VS, WT, BMI.
Check all Consult Notes.
Photographs (optional).
Educational Assessment Tools.
Consents.
Pre-Operative Visit
Preoperative Instructions
Verbal and Written
Be Explicit Bowel Prep
Pre-Operative Visit Patient Education
Pre-admission orders including any bowel preparation,meal restrictions, NPO instructions
When to arrive at the hospital and what to bring
What will take place prior to surgery
Waking up in the PACU after the operation and the importance of early ambulation
Pain management
Introduction of fluids and diet progression
Pre-Operative Visit Patient Education
Maximizes the patient’s success potential.
Decreases stress from lack of knowledge
Helps Set appropriate expectations.
Pre-Operative Visit Prophylactic ABx
First Generation cephalosporin before induction and 12 hours post-op.
Vancomycin if allergic to penicillin.
Same as any UGI Procedure.
Pre-Operative Visit Preo-op Diet
Low calorie,Low carb,High protein liquids for 2 weeks pre-op.
Helps control blood sugar peri-op.
Technically helps with the size of the liver.
Information Meetings/Support Groups.
Help consolidate the informations about peri-op expectations and care.
Focus on the change in lifestyle and commitment for better results.
Sharing personal experience.
Psychological Evaluation
The psychological evaluation can be used to identify psychiatric disorders, provide treatment referrals, and flag any contraindications for surgery.
It also provides an opportunity to educate patients, resolve ambivalence, and build motivation.
Psychological Evaluation
Accountability Stability - Will surgery disrupt it?
Situational vs. clinical depression(treated/unt reated) pre op treatment) History of eating disorders Anorexia/Bulimia
Absence of mental illness Setting goals & realistic expectations Support system Ability & willingness to make lifetime changes Safe setting (domestic dynamics) Substance abuse Suicide attempts
Psychological Evaluation Patient History
History of any psychiatric problems.
History of dieting and binge eating.
Results of any previous evaluations or treatment.
Previous weight loss attempts.
Relevant personal and family information.
Medication and dietary supplements.
Psychological Evaluation Patient Knowledge Gaps
A significant minority of patients - Believe that surgery makes it impossible to overeat (25%).
- Have unrealistic weight loss expectations (19% high and 30% low).
- Do not know the symptoms of dumping (>20%).
- Believe there is no need to worry if depression occurred in the postoperative period (27%).
Gonder-Frederick et. al., Bariatric Times, Nov./Dec. 2004
Psychological Evaluation Possible contraindications for surgery
Concerns about patient’s ability to give informed consent or comply with behavior changes required after operation.
Current severe or uncontrolled psychopathology such as alcoholism, schizophrenia, or bipolar disorder
Psychological Evaluation Possible contraindications for surgery
patients who have ever had an Axis I clinical disorder, especially mood or anxiety, exhibit poorer weight outcomes 6 months after gastric bypass than those who have never had an Axis I disorder.
Kalarchian MA et al..Surg Obes Relat Dis. 2008 Jul-Aug;4(4):544-9
Psychological Evaluation Patient Goals and Expectations
Some patients may have unrealistic goals and expectations for weight loss.
Personal goals and expectations may affect success at long-term weight control.
The behavioral health provider may provide psychoeducation, foster realistic expectations, and build motivation.
Psychological Evaluation Treatment Recommendations
Empirically supported treatments exist for many psychiatric disorders potentially relevant to the bariatric surgery patient.
Eating disorders (e.g., binge eating).
Mood disorders (e.g., depression).
Anxiety disorders. Borderline personality disorder.
Psychological Evaluation What Psychologists can do ?
Screen out inappropriate patients.
Evidence not promising; research is needed Active substance abuse, psychiatric personality disorder, suicide ideation
Teaching candidates to be good patients.
Attend support groups, reading, learning What constitutes a “good patient?”
Psychological Evaluation Possible Complicating Factors
Poorly managed psychopathology
Depression, Anxiety, Bi-polar, Bulimia etc..
Borderline personality disorder
Active alcohol or substance abuse
Recent hospitalization (mental disorder)
History of postoperative complications
Psychological Evaluation Possible Positive Predictors or Factors
Social/Emotional support network
Family, Friends.
Optimism, positive attitude
Humor
Knowledge of surgery, diet, etc..
Compliance may be the best indicator of successful outcome
Psychological Evaluation What “Pre-Ops” Want ?
Self-esteem Energy Happiness, optimism Depression Physical symptoms Medications
Patients Report Dramatic Changes After Surgery
Able to breathe easily.
Able to sleep & wake up refreshed.
Free from snoring & apnea.
Off most pre-op meds.
Free from joint pain.
More active and less fatigued Resolution of chronic issues like skin rashes.
Relief from depression Excited to start a new day Happy to look in the mirror when getting ready for work Experienced improvement in work arena, i.e. promotion, new duties, raises etc.
Able to pursue new hobbies and interests. Self confident.
Psychological Evaluation What “Post-ops” Get ?
Positives: Psychological
Self esteem Happiness, optimism Body image Emotional access Depression Food obsession
Psychological Evaluation What “Post-ops” Get ?
Positives: Social
Going out, trying new activities Socializing Intimacy Sex, libido Dating, flirting
Psychological Evaluation What “Post-ops” Get ?
Positives: Physical
Health (general) Energy Mobility (activities of daily living) Physical symptoms (sleep dsrpt, arthritis)
Clothing
Psychological Evaluation Psychosocial Outcomes
Improvements in social relations and employment.
Reductions in depression and anxiety.
Decreases in binge eating.
Herpertz et. al, 2003; Bocchieri et. al, 2002
Conclusion Clinical Decision Making
There are no well-established predictors of surgery outcome.
There are few alternative treatments for individuals who qualify for surgery
Conclusion Decisional Balance
CONS Potential for complications.
Careful medical monitoring for life
Miss time from work
Feeling like a failure.
PROS Long-term weight control.
I’ll have a tool to help. me eat less food at each meal.
Perform better at my job.
Helps improve my diabetes and reduce my medications.
Postoperative Eating Problems
Although surgery has a positive impact overall,some patients do experience the onset of eating disorders after bariatric surgery (or other behavioral health concerns).
Eating disorders may be most common among those who had binge eating or other eating problems prior to operation
.