ESPEN Congress Geneva 2014LLL LIVE COURSE: NUTRITION IN OBESITY

Pre-operative medical assessment, post-operative follow-up and clinical outcome in bariatric surgery patientsA. Thorell (SE)

Nutrition in obesity• Pre-operative medical assessment, post-

operative follow-up and clinical outcome in bariatric surgical patients

Anders Thorell MD, PhD• Karolinska Institutet & Department of

Surgery, Ersta Hospital

Stockholm, Sweden

Ethical dilemmasBioethical principlesApplication of bioethical

principles to “Nutrition at the end-of-life”

The decision-making process

Outline

• Treatment modalities• Indications for bariatric surgery• Bariatric surgical procedures• Preoperative assessement• Postop follow-up• Clinical outcome

Obesity - Treatment modalities

• Diet regimens• Behavioural therapy • Physical activity• Pharmacological• Surgical (Bariatric surgery)

Bariatric surgery- indications

• BMI > 40 kg/m2 or• BMI > 35 kg/m2 with comorbidity• Earlier ”serious” weight-reducing attempts• No major eating disorders

– BED (Binge eating disorder)– AN (Anorexia nervosa)

• Well informed• Well motivated

Bariatric surgical procedures

• Restrictive– Vertical banded gastroplasty– Adjustable gastric banding– Sleeve gastrectomy– Gastroplication

• Malabsorptive– Biliopancreatic diversion– Biliopancreatic diversion with duodenal

switch

• Combined– Roux-en-Y gastric bypass

Vertical banded gastroplasty

Adjustable Gastric Banding

Sleeve resection

Gastroplication

11

Gastroplication

12

Biliopancreatic diversion

Biliopancreatic diversion with duodenal switch

Roux-en-Y Gastric bypass

Bariatric procedures trends

Buchwald & Oien, Obes Surg 2013

010203040506070

2003 2008 2011

% p

roce

dure

s

Gastric Band

Gastric Bypass

Sleeve Gastrectomy

BPD/DS

Mini GB

Worldwide: 146 000 344 000 340 000Europe: 33 000 67 000 113 000

Preoperative assessment

• Aim to ensure that:

• Comorbidities are identified and optimized• Patients are well informed regarding:

– Expected outcome/risks– Importance of adherence to postop regimens

• Well motivated and willing

Preoperative assessment

• Multidisciplinary team:

• Bariatric surgeon• Internist• Anaesthesist• Dietician• Specialist nurse• Psychologist/Psychiatrist

Preoperative assessment

• General

• Identify risk factors that increase risk:• Cariovascular

– Iscaemic heart disease– Thromboembolic events– Unregulated hypertension

• Metabolic disease (diabetes)• Previous surgery (adhesions)

Preoperative assessment

• Procedure specific:

• RYGB– Inflammatory Bowel Disease– Premalignant gastric conditions– H.Pylori

• Sleeve gastrectomy– Gastroesophageal reflux disease

Postoperative Follow-up- Complications

• Early – Postoperative complications

• Anastomotic leak• Bleeding• Infections• Thromboembolic events

• Late– Complications

• Internal herniation• Stomal ulcers

– Chronic pain– Nutitional deficiencies

Early complications (< 1 week)

• Symptoms– Abdominal pain– Tachycardia– Fever– Nausea/vomiting– Respiratory distress

• Actions– Blood sampling– Upper endoscopy– Radiology– Immediate surgical intervention

Long term follow up

• 6 weeks, 6 months, annually– Athropometrics– Blood sampling– Prescription of supplementation:

• Multivitamin• Cobolamine (Vitamin B12)• Calcium Citrate• Vitamin D• Iron (Menstruating women)

• Councelling– Dietary– Lifestyle

Long term follow up

• Procedure specific– Band Adjustment (AGB)– VBG, Sleeve: only multivitamin supplementation– Malabsorptive: More extensive laboratory checks

• Outcome dependent on adherence tofollow-up!

Outcome after bariatric surgeryWeight (SOS)

Sjöström L et al. NEJM 2007

Outcome after bariatric surgeryDiabetes incidence (SOS)

Sjöström L et al NEJM 2004;351:2683-2693

Odds ratio: 0.14 0.2595% CI: 0.08 - 0.24 0.17 - 0.38N control 1402 539N surgery 1489 517

Outcome after bariatric surgeryDiabetes remission (SOS)

Sjöström L et al NEJM 2004;351:2683-2693

Outcome after bariatric surgeryHbA1c (Randomized)

Schauer et al NEJM 2014

Outcome after bariatric surgeryCardiovascular disease (MI)

Schauer et al NEJM 2014

HR = 0.71595% CI: 0.518 to 0.987

P= 0.0411

-28.5%Individualswith MI, n

Control 87Surgery 64

0

2

4

6

8

Cum

ulat

ive

inci

denc

e, %

0 2 4 6 8 10 12 14 16Years of follow up Sjöström et al NEJM 2006

Outcome after bariatric surgery- Mortality (SOS)

HR = 0.71595% CI: 0.518 to 0.987

P= 0.0411

-28.5%

0

2

4

6

8

0 2 4 6 8 10 12 14Years of follow up

Sjöström L et al NEJM 2004;351:2683-2693

Outcome after bariatric surgery- Kidney function

HR = 0.71595% CI: 0.518 to 0.987

P= 0.0411

0

2

4

6

8

0 2 4 6 8 10 12Years of follow up

Iaconelli et al. Diabetes Care 2011

Summary

• Volumes of bariatric surgery increasing• Effects on:

– Weight– Co-morbidities– Quality of life– Mortality

• Invasive procedures (risks) • Pre- and postop assessment crucial• Life-long follow up mandatory