Obesity & Related Surgical Procedures

Obesity & Related Obesity & Related Surgical ProceduresSurgical Procedures

RNSG 1247RNSG 1247

Obesity and OverweightObesity and Overweight

Obesity is an abnormal Obesity is an abnormal increase in increase in the proportion of fat cellsthe proportion of fat cells

Primarily occurs in the visceral and Primarily occurs in the visceral and subcutaneous tissues of the body subcutaneous tissues of the body

Trends in Obesity* Prevalence (%), Children and Adolescents, by Age Group, US, 1971-

2006

*Body mass index (BMI) at or above the sex-and age-specific 95th percentile BMI cutoff points from the 2000 sex-specific BMI-for-age CDC Growth Charts. Note: Previous editions of Cancer Statistics used the term “overweight” to describe youth in this BMI category.Source: National Health and Nutrition Examination Survey, 1971-1974, 1976-1980, 1988-1994, 1999-2002, National Center for Health Statistics, Centers for Disease Control and Prevention, 2002, 2004. 2003-2006: Ogden CL, et al. High Body Mass Index for Age among US Children and Adolescents, 2003-2006. JAMA 2008; 299 (20): 2401-05.

54

65

7

5

7

11 1110

16 16

12

1718

0

5

10

15

20

2 to 5 years 6 to 11 years 12 to 19 years

Pre

va

len

ce

(%

)

NHANES I (1971-74) NHANES II (1976-80) NHANES III (1988-94)

NHANES 1999-2002 NHANES 2003-2006

Trends in Obesity* Prevalence (%), By Gender, Adults Aged 20 to 74, US,

1960-2006†

*Obesity is defined as a body mass index of 30 kg/m2 or greater. † Age adjusted to the 2000 US standard population. Source: National Health Examination Survey 1960-1962, National Health and Nutrition Examination Survey, 1971-1974, 1976-1980, 1988-1994, 1999-2002, National Center for Health Statistics, Centers for Disease Control and Prevention, 2002, 2004. 2003-2004, 2005-2006: National Health and Nutrition Examination Survey Public Use Data Files, 2003-2004, 2005-2006, National Center for Health Statistics, Centers for Disease Control and Prevention, 2006, 2007.

1311

1615

12

1715

13

17

2321

26

3128

3433 323535

3436

0

5

10

15

20

25

30

35

40

45

Both sexes Men Women

Pre

vale

nce

(%)

NHES I (1960-62) NHANES I (1971-74) NHANES II (1976-80) NHANES III (1988-94)

NHANES 1999-2002 NHANES 2003-2004 NHANES 2005-2006

Etiology and PathophysiologyEtiology and Pathophysiology

Genetic/Biologic basisGenetic/Biologic basisEnvironmental factors Environmental factors Psychological factorsPsychological factors

** Most common form considered to ** Most common form considered to be polygenic, arising from the be polygenic, arising from the interaction of multiple genetic and interaction of multiple genetic and environmental factorsenvironmental factors

Hormones & Peptides that Hormones & Peptides that Interact with Hypothalamus to Interact with Hypothalamus to

Effect ObesityEffect Obesity

Fig. 41-3Fig. 41-3

Classification of Body Weight Classification of Body Weight and Obesityand Obesity

Primary obesity (Primary obesity (majority of obesemajority of obese))Excess caloric intake for the body’s Excess caloric intake for the body’s

metabolic demandsmetabolic demandsSecondary obesitySecondary obesity

Results from various congenital Results from various congenital anomalies, chromosomal anomalies, anomalies, chromosomal anomalies, metabolic problems, or CNS lesions and metabolic problems, or CNS lesions and disordersdisorders


Body mass index (BMI)Body mass index (BMI)Used to classify underweight, healthy Used to classify underweight, healthy

(normal) weight, overweight, or obese(normal) weight, overweight, or obeseCommon clinical index of obesity or Common clinical index of obesity or

altered body fat distributionaltered body fat distributionUses weight-to-height ratiosUses weight-to-height ratios

BMI chartBMI chart

Weight for height chartWeight for height chart


Waist-to-hip ratio (WHR)Waist-to-hip ratio (WHR)Preferred tool when predominantly Preferred tool when predominantly

muscularmuscularWaist measurement/hip measurement = Waist measurement/hip measurement =

ratioratioWHR <0.80 is optimalWHR <0.80 is optimalVisceral fat Visceral fat increases risk for increases risk for

cardiovascular disease and metabolic cardiovascular disease and metabolic syndromesyndrome

Visceral FatVisceral Fat

Subcutaneous FatSubcutaneous Fat

Classification of Body ShapesClassification of Body Shapes

Apple-shaped bodyApple-shaped bodyFat located primarily in the abdominal areaFat located primarily in the abdominal areaAt greater risk for obesity-related At greater risk for obesity-related

complicationscomplicationsAndroid obesityAndroid obesity

Pear-shaped bodyPear-shaped bodyFat located primarily in upper legsFat located primarily in upper legsGynoid obesityGynoid obesity

Classification of Body ShapesClassification of Body Shapes

....

Fig. 41-5Fig. 41-5

Health Risks Associated with Health Risks Associated with ObesityObesity

Problems occur at Problems occur at higherhigher rates for obese rates for obese patientspatients

Mortality rate rises as obesity increasesMortality rate rises as obesity increases Especially with Especially with increased increased visceral fatvisceral fat

Obese patients have a Obese patients have a decreaseddecreased quality quality of lifeof life

Most conditions improve with weight lossMost conditions improve with weight loss

Health Risks Associated with Health Risks Associated with ObesityObesity

Fig. 41-6Fig. 41-6

Nursing ProblemsNursing Problems

Imbalanced nutritionImbalanced nutritionChronic low self-esteemChronic low self-esteemOthers related to complicationsOthers related to complications

PlanningPlanning

Modify eating patternsModify eating patternsParticipate in a regular physical Participate in a regular physical

activity programactivity programAchieve weight loss to a specified Achieve weight loss to a specified

levellevelMaintain weight loss at a specified Maintain weight loss at a specified

levellevelMinimize or prevent health problems Minimize or prevent health problems

related to obesityrelated to obesity

Management: Non-surgical Management: Non-surgical

NutritionNutritionExerciseExerciseBehavior modificationBehavior modificationSupport groupsSupport groupsDrug therapyDrug therapy

NutritionNutrition

ExerciseExercise

Trends in Prevalence (%) of High School Students Attending PE Class Daily, by

Grade, US, 1991-2007

9th

10th

11th

12th

0

10

20

30

40

50

60

70

1991 1993 1995 1997 1999 2001 2003 2005 2007

Year

Pre

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(%

)

Source: Source: Youth Risk Behavior Surveillance System, 1991, 1995, 1997, 1999, 2001, 2003, 2005, 2007 National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 2008.

Behavior modificationBehavior modification

Basic techniques includeBasic techniques include

Self monitoringSelf monitoringStimulus controlStimulus controlRewards – short term vs long term, Rewards – short term vs long term,

what’s acceptable vs unacceptable what’s acceptable vs unacceptable

Support groupsSupport groups

Drug TherapyDrug Therapy

Appetite-suppressing drugs or Appetite-suppressing drugs or Sympathomimetic drugs for _____ Sympathomimetic drugs for _____ term use term use Decrease food intake through Decrease food intake through

nonadrenergic or serotonergic nonadrenergic or serotonergic mechanisms in the CNSmechanisms in the CNS

Phentermine – most commonly Phentermine – most commonly prescribed; causes appetite ___________ prescribed; causes appetite ___________ and _________ food intake and _________ food intake Other exs: Diethylpropion, PhendimetrazineOther exs: Diethylpropion, Phendimetrazine


Appetite-suppressing drugs or Appetite-suppressing drugs or Sympathomimetic drugs for ______ Sympathomimetic drugs for ______ term useterm useMixed nonadrenergic–serotonergic Mixed nonadrenergic–serotonergic

agentsagentsDo not stimulate release of serotonin Do not stimulate release of serotonin Sibutramine (Meridia) – works by increasing Sibutramine (Meridia) – works by increasing

__________________________


Nutrient absorption-blocking drugs Nutrient absorption-blocking drugs (GI lipase inhibitors)(GI lipase inhibitors)Work by blocking fat breakdown and Work by blocking fat breakdown and

absorption in intestine absorption in intestine Orlistat (Xenical) Orlistat (Xenical)


Drugs that ↑ energy expenditure are Drugs that ↑ energy expenditure are not approved by the FDA. Ex: not approved by the FDA. Ex: EphedrineEphedrine

Appetite-suppressing drugs removed Appetite-suppressing drugs removed from market from market

fenfluramine (Pondimin)fenfluramine (Pondimin)dexfenfluramine (Redux)dexfenfluramine (Redux)

Bariatric SurgeryBariatric Surgery

Used to treat morbid obesityUsed to treat morbid obesityCurrently the only treatment found to Currently the only treatment found to

have a successful and lasting impact have a successful and lasting impact for sustained weight lossfor sustained weight loss


Must meet all of the following criteria Must meet all of the following criteria to be considered an ideal candidateto be considered an ideal candidateBMI BMI ≥40 kg/m≥40 kg/m2 2 with one or more with one or more

obesity-related complicationobesity-related complication18 years or older18 years or olderUnderstands the risks and benefits Understands the risks and benefits Has been obese for >5 yearsHas been obese for >5 yearsHas tried and failed to lose weightHas tried and failed to lose weight


Criteria to be considered an ideal Criteria to be considered an ideal candidate (cont’d)candidate (cont’d)Has no serious endocrine problemsHas no serious endocrine problemsHas psychiatric and social stability Has psychiatric and social stability Availability of a team of health care Availability of a team of health care

providersprovidersSurgery would Surgery would ↓ or eradicate high-risk ↓ or eradicate high-risk

conditionsconditions


Three broad categoriesThree broad categoriesRestrictiveRestrictiveMalabsorptive Malabsorptive Combination of restrictive and Combination of restrictive and

malabsorptive malabsorptive

Restrictive SurgeryRestrictive Surgery

Reduces the size of a stomach to 30 Reduces the size of a stomach to 30 ml or lessml or less

Causes patient to feel full quickerCauses patient to feel full quickerNormal stomach digestion and Normal stomach digestion and

intestinal absorption of foodintestinal absorption of food↓ ↓ Risk of anemia and cobalamin Risk of anemia and cobalamin

deficiencydeficiency


Vertical banded gastroplastyVertical banded gastroplastyPartitions stomach into a small pouch in Partitions stomach into a small pouch in

upper portion upper portion Small pouch drastically limits capacitySmall pouch drastically limits capacityStoma opening to rest of stomach is Stoma opening to rest of stomach is

banded to delay emptying of solid food banded to delay emptying of solid food from proximal pouchfrom proximal pouch


Adjustable gastric banding (AGB)Adjustable gastric banding (AGB)Also referred to as the LapBandAlso referred to as the LapBandStomach size is limited by an inflatable Stomach size is limited by an inflatable

band placed around fundus of stomachband placed around fundus of stomachBand is connected to a subcutaneous Band is connected to a subcutaneous

portportCan be inflated or deflated to change Can be inflated or deflated to change

stoma size stoma size


AGB (cont’d)AGB (cont’d)Can be done laparoscopically and can Can be done laparoscopically and can

be modified or reversed be modified or reversed Better choice for patients who are Better choice for patients who are

surgical riskssurgical risksWeight loss is slower than in other Weight loss is slower than in other

proceduresprocedures

Restrictive SurgeriesRestrictive SurgeriesFig. 41-7AFig. 41-7A

Malabsorptive Surgeries Malabsorptive Surgeries

Biliopancreatic diversion (BPD)Biliopancreatic diversion (BPD)Removes ~3/4 of stomach to Removes ~3/4 of stomach to ↓↓ food food

intake and intake and ↓ acid output↓ acid outputRemaining 1/4 of stomach is connected Remaining 1/4 of stomach is connected

to lower portion of small intestine to lower portion of small intestine Pancreatic enzymes and bile enter final Pancreatic enzymes and bile enter final

segment of intestinesegment of intestineNutrients pass without being digestedNutrients pass without being digested

Malabsorptive Surgeries Malabsorptive Surgeries

Biliopancreatic diversion with Biliopancreatic diversion with duodenal switchduodenal switchVariation of BPDVariation of BPDBy including duodenal switch, surgeons By including duodenal switch, surgeons

leave a larger portion of the stomach leave a larger portion of the stomach intactintact

Helps prevent dumping syndromeHelps prevent dumping syndrome

BPD with or w/o doudenal BPD with or w/o doudenal switchswitch

Bariatric Surgeries

How is weight loss accomplished?What are the specific nutritional risks

or adverse effects?What should be monitored to avoid

complications?What is/are the advantage/s over

other procedures?

Combination of Restrictive Combination of Restrictive and Malabsorptive Surgeryand Malabsorptive Surgery

Roux-en-Roux-en-YY surgical procedure surgical procedureHas low complication ratesHas low complication ratesExcellent patient toleranceExcellent patient toleranceStomach size is Stomach size is ↓ with a gastric pouch ↓ with a gastric pouch

anastomosis that empties directly into anastomosis that empties directly into jejunumjejunum

Combination of Restrictive Combination of Restrictive and Malabsorptive Surgeryand Malabsorptive Surgery

Roux-en-Roux-en-YY surgery (cont’d) surgery (cont’d) VariationsVariations

Stapling stomach without transection to Stapling stomach without transection to create a small 20- to 30-ml gastric pouchcreate a small 20- to 30-ml gastric pouch

Creating an upper and lower gastric pouch Creating an upper and lower gastric pouch and totally disconnecting the pouchesand totally disconnecting the pouches

Creating an upper gastric pouch and Creating an upper gastric pouch and completely removing the lower pouchcompletely removing the lower pouch


Fig. 41-7DFig. 41-7D

Cosmetic SurgeriesCosmetic Surgeries

Ideal candidates have Ideal candidates have Achieved weight reduction Achieved weight reduction Excess skinfolds or fatExcess skinfolds or fat

Chooses surgery for cosmetic Chooses surgery for cosmetic reasonsreasonsLipectomyLipectomyLiposuctionLiposuction

Preoperative CarePreoperative Care

Patients who are obese are likely to Patients who are obese are likely to suffer other comorbidities, such as suffer other comorbidities, such as Diabetes, altered cardiorespiratory Diabetes, altered cardiorespiratory

function, abnormal metabolic function, function, abnormal metabolic function, atherosclerosis atherosclerosis

An interdisciplinary team approach An interdisciplinary team approach may be necessarymay be necessary


Have room ready for patient prior to Have room ready for patient prior to arrivalarrivalLarger size BP cuff, gown Larger size BP cuff, gown Bariatric wheelchairBariatric wheelchair

Or a wheelchair with removable arms Or a wheelchair with removable arms Strongly reinforced trapeze bar over bed Strongly reinforced trapeze bar over bed

for movement and positioningfor movement and positioning


Obtaining venous access may beObtaining venous access may be

complicatedcomplicated Assistance may be neededAssistance may be needed Multiple tourniquets Multiple tourniquets May need a longer catheter inserted far May need a longer catheter inserted far

enough into the vein enough into the vein

Preoperative CarePreoperative CareObesity can make breathing shallow Obesity can make breathing shallow

and rapidand rapid Instruct patient in proper Instruct patient in proper

Coughing techniques, deep, Coughing techniques, deep, diaphragmatic breathingdiaphragmatic breathing

Methods of turning and positioning to Methods of turning and positioning to prevent pulmonary complicationsprevent pulmonary complications


Wound infection is one of the most Wound infection is one of the most common complications common complications

Skin preparation is important Skin preparation is important Ask patient to bathe or shower Ask patient to bathe or shower

frequently for a few days before frequently for a few days before admissionadmission

Care to prevent wound dehiscence Care to prevent wound dehiscence when coughing when coughing

Postoperative CarePostoperative CareDuring transfer ensure that patient’sDuring transfer ensure that patient’s

Airway is stabilized Airway is stabilized Pain is managedPain is managed

Early __________ is essential Early __________ is essential Patients undergoing bariatric surgery Patients undergoing bariatric surgery

are often in considerable _________ are often in considerable _________ ________

Patient is now _______ ______ Patient is now _______ ______ due to due to anatomic changesanatomic changes

Ambulatory and Home CareAmbulatory and Home Care

Diet prescribed is generally Diet prescribed is generally High protein High protein Low in carbohydrates fats & roughageLow in carbohydrates fats & roughage 6 small feedings6 small feedings Fluids not to be ingested with meals : Fluids not to be ingested with meals :

< 1000 ml/day< 1000 ml/day

first 24 hrs post-op = water, sugar-free liquids Q 2hrs WAfirst 24 hrs post-op = water, sugar-free liquids Q 2hrs WA

Day 1 to 2 wks = high protein liquids Q 2hrs WADay 1 to 2 wks = high protein liquids Q 2hrs WA

2-4 wks = pureed at frequent intervals2-4 wks = pureed at frequent intervals

4-6 wks = transition diet w/solids & pureed4-6 wks = transition diet w/solids & pureed

Ambulatory and Home CareAmbulatory and Home Care

Possible complications from surgeryPossible complications from surgeryAnemia Anemia Vitamin deficiencies Vitamin deficiencies Diarrhea Diarrhea Psychiatric problemsPsychiatric problemsPeptic ulcer formationPeptic ulcer formationDumping syndromeDumping syndromeSmall bowel obstruction Small bowel obstruction

EvaluationEvaluation

Expected outcomesExpected outcomesLong-term weight lossLong-term weight lossImprovement in obesity-related Improvement in obesity-related

comorbiditiescomorbiditiesIntegration of healthy practices into Integration of healthy practices into

lifestylelifestyleMonitoring possible adverse side effects Monitoring possible adverse side effects Improved self-image Improved self-image

Gerontologic ConsiderationsGerontologic Considerations

Number of older obese persons has Number of older obese persons has risen risen

More common in women than menMore common in women than menDecreased energy expenditure and Decreased energy expenditure and

loss of muscle mass are important loss of muscle mass are important contributorscontributors

Exacerbates age-related problemsExacerbates age-related problems

Metabolic SyndromeMetabolic Syndrome

A group of risk factors that increase A group of risk factors that increase an individual’s chance of developing an individual’s chance of developing cardiovascular disease and diabetes cardiovascular disease and diabetes mellitusmellitus

Metabolic SyndromeMetabolic Syndrome

Risk factors: Risk factors:

abdominal obesity, insulin resistanceabdominal obesity, insulin resistanceDiagnostic criteria: Diagnostic criteria: 1.1. Waist circumferenceWaist circumference

2.2. TriglyceridesTriglycerides

3.3. HDLHDL

4.4. BPBP

5.5. Fasting glucoseFasting glucose

Obesity & Related Surgical Procedures

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