Obesity & Related Surgical Procedures
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Transcript of 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.
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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.
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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
Classification of Body Weight Classification of Body Weight and Obesityand Obesity
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
Classification of Body Weight Classification of Body Weight and Obesityand Obesity
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
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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
Drug TherapyDrug Therapy
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
__________________________
Drug TherapyDrug Therapy
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)
Drug TherapyDrug Therapy
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
Bariatric SurgeryBariatric Surgery
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
Bariatric SurgeryBariatric Surgery
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
Bariatric SurgeryBariatric Surgery
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
Restrictive SurgeryRestrictive Surgery
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
Restrictive SurgeryRestrictive Surgery
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
Restrictive SurgeryRestrictive Surgery
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
Restrictive SurgeryRestrictive Surgery
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
Preoperative CarePreoperative Care
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
Preoperative CarePreoperative Care
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
Preoperative CarePreoperative Care
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