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Case study 2: Bariatric Surgery

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Shamma AlMutaiwei

on 7 March 2015

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Transcript of Case study 2: Bariatric Surgery

Thank You!
Case Study 2
Bariatric Surgery for Morbid Obesity

Afra Khalid 201203881
Shamma Salem 201201590

Dr. Rola Mechli

Introduction
Patient Information:

37 years old white male
Morbidly obese his entire life
Admitted for Roux-en-Y gastric bypass surgery
Highest weight six: 197Kg,
But he lost 11Kg
Current weight: 186Kg
Height: 177.8 Cm.
Mr. Chris McKinley
Patient Information:
Type 2 diabetes mellitus
Hypertension
Hyperlipidemia
Osteoarthritis
Surgery 3 years ago for an R total knee replacement
Patient Information:
Metformin: lowers the insulin and blood sugar level,
Lantus: long acting insulin medication
Lasix: diuretic to treat fluid retention and hypertension
Lovastatin: lowers LDL and triglycerides.
Medications:
At higher risk of developing coronary artery disease because of:


Family history
Medical history
Vital signs
HEENT evaluation
Skin assessment
Abdomen & bowel assessment
Blood test
Urine test
Skin Test Results:
• Warm & dry skin

• Presence of ecchymosis
which is bruises on the skin due to morbid obesity

• Abrasions & rash
due to the skinfolds and weight pressure

• At low risk of developing pressure sores
Braden score

• +2 pitting edema

Blood Test Results:
Questions
Question 1:
Discuss the classification of morbid obesity.
The classification of obesity is based on calculating body mass index (BMI),
which is the most widely accepted method in determining obesity since it is quick and easy.

BMI of 30 – 34.9 Kg/m2 : Class 1 obesity
BMI of 35 – 39.9 Kg/m2 : Class 2 obesity
BMI of ≥ 40 Kg/m2 : Class 3 obesity
(Morbid Obesity)


Defining obesity base on body fat percentage,

> 25% fat in males
> 33% fat in females

Urine Test Results:
Question 2:
Describe the primary health risks involved with untreated morbid obesity. What health risks does Mr. McKinley present with
Health risks associated with untreated morbid obesity include:
- High blood pressure
- Heart diseases
- Dyslipidemia
- Type 2 diabetes mellitus
- Respiratory complications
- Gastroesophageal reflux
- Degenerative Arthritis
- Venous Insufficiency
- Skin infections
- Infertiltiy


Health risks present in Mr. McKinley:

- Dyslipidemia
- Type 2 diabetes mellitus
- Hypertention
- Osteoarthritis


Question 12:
Determine Mr. McKinley’s energy and protein requirements. Explain the rationale for the method you used to calculate these requirements.
Question 13:
After reading the physician’s history and physical, identify any signs or symptoms that are most likely a consequence of Mr. McKinley’s morbid obesity.
Question 11:
Assess Mr. McKinley’s height and weight. Calculate his BMI and % usual body weight. What would be a reasonable weight goal for Mr. McKinley? Give your rationale for the method you used to determine this.
Question 10:
Mr. McKinley’s RD has discussed the importance of hydration, protein intake, and intakes of vitamins and minerals, especially calcium, iron, and B12. For each of these nutrients, describe why intake may be inadequate and explain the potential complications that could result from deficiency.
Question 9:
Over the next two months, Mr. McKinley will be progressed to a pureed-consistency diet with 6-8 small meals. Describe the major goals of this diet for the Roux-en-Y patient. How might the nutrition guidelines differ if Mr. McKinley had undergone a Lap-Band procedure?
Question 8:
On post-op day one, Mr. McKinley was advanced to the Stage 1 Bariatric Surgery Diet. This consists of sugar-free clear liquids, broth, and sugar-free Jell-O. Why are sugar-free foods used?
Question 7:
Mr. McKinley has had type 2 diabetes for several years. His physician shared with him that after surgery he will not be on any medications for his diabetes and that he may be able to stop his medications for diabetes altogether. Describe the proposed effect of bariatric surgery on the pathophysiology of type 2 diabetes. What, if any, other medical conditions might be affected by weight loss?
Question 6:
Question 5:
Describe the following surgical procedures used for bariatric surgery including advantages, disadvantages, and potential complications.
Adjustable Gastric Banding (Lap-Band):
Question 3:
What are the standard adult criteria for consideration as a candidate for bariatric surgery? After reading Mr. McKinley’s medical record, determine the criteria that allow him to qualify for surgery.
Adult Criteria
- BMI is 40 or higher
- BMI is >35 with comorbid conditions:
- Type 2 diabetes
- Cardiovascular disease
- Hypertension
- Dyslipidemia
- Sleep apnea.
- Unsuccessful weight lose with exercise and diet




- Morbidly obese
- BMI of 58.8 kg/m2
- Weight related health problems:
- Type 2 diabetes
- Dyslipidemia
- Hypertension.


Mr. McKinley is a candidate for bariatric surgery:
Roux-en-Y Gastric bypass:
Duodenal switch:
Vertical Banded Gastroplasty:
Vertical Sleeve Gastrectomy:
Biliopancreatic Diversion:
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Advantages
· Average weight loss by 75%.
· Decrease food intake and increase satiety.
· Improvement in associated health condition
- Sleep apnea - Hypertension
- Type 2 diabetes - Back pain
- Depression - Cardiovascular diseases
· Small incisions
· Less complications.
· Low mortality rate 0.2% - 1%
Disadvantages
· Non-reversible
· Malnutrition due to the small surface
area of absorption.
· Vitamins and mineral deficiency.
· Lifelong vitamin and mineral
supplementation.


· 10% - 20% of patients require follow-up
operation for corrections.
· Leaking through sutures.
· Bowel obstruction.
· Ulcers in stomach and intestine.
· Stretching of the pouch.
· Dumping syndrome that cause nausea
and diarrhea.
· Vomiting and abdominal pain.
· Gallbladder inflammation and gallstones.
· Anemia, osteoporosis, and metabolic bone
disease.
Potential complications:
Advantages
Disadvantages
Potential Complications
· Decrease Appetite due to removal part
of the stomach that produces Ghrelin
hormone.
· Rapid weight loss, about 65%.
· Low chance of nutritional deficiencies,
no malabsorption.
· Laparoscopic procedure.
· Non-reversible.
· Stretching the new stomach
· Some patient may gain weight, and some
patient may lose more than the desired
weight.
· Potential leaks through sutures.
· May cause acid reflux and esophagus
inflammation.
· Vomiting due to excess food intake that
the new stomach can’t hold it.
Advantages
· It does not include any cutting, stapling,
or bypassing of the stomach and
intestines.
· The band is adjustable.
· Less post-operate stay in the hospital.
· Simplest and most common procedure.
Disadvantages
· Slow rate of losing weight compared to
other gastric surgeries.
Potential Complications
· High risk of developing gallstones.
· Risk of stomach injury during the
procedure, such as, tear in the stomach.
· Nausea, vomiting, acid reflux, and
abdominal pain.
· The band may slip out of its place
· Eroding of the band, which must be
removed in this case.
Advantages
Disadvantages
Potential Complications
Potential Complications
Potential Complications
Advantages
Disadvantages
Advantages
Disadvantages
· Does not change the digestive
pathway.
· Decrease food intake.
· No risk of malabsorption
· Longer stay at the hospital
· Complex surgery to reverse the
procedure
· Restricted diet after the surgery
· Gastric leak
· Nausea and vomiting
· Disruption or breaking of staples
· Enlargement of the pouch
· Acid reflux
· The band may slip out of its place
· Eroding of the band, which must be
removed in this case.
· Less dumping syndrome than other
surgeries.
· High weight loss.
· Development of malnutrition due to the
small surface area of absorption.
· Vitamins and mineral deficiency.
· Mainly done as an open procedure
· Developing anemia and osteoporosis
since absorption area is decreased.
· Internal bleeding
· Abdominal infections
· Leaking

· Significant weight loss about 70%-90% of total
body weight
· Most effective procedure for weight loss and
maintaining weight
· Improvement in associated health condition, such
as, sleep apnea, hypertension, reverse type 2
diabetes, back pain, depression, and
cardiovascular diseases.
· Stretching of the pouch
· Development of malnutrition due to the
small surface area of absorption.
· Vitamins and mineral deficiency.
· Lifelong vitamin and mineral
supplementation.
· Acid reflux
· Intestinal ulcers.
· Developing anemia and osteoporosis since
absorption area is decreased.
· Internal bleeding
· Abdominal infections
· Leaking
Type 2 diabetes is usually treated by weight loss.
After surgery
Weight Loss
Restricted Food
(Kashyap, 2010)
Control Blood Glucose
Increase
Insulin Sensitivity
Other medical conditions that are affected by weight loss surgeries:
Hypertension

Hyperlipidemia

Sleep apnea


Hypertension
Weight Loss
Low Blood Pressure
Less Strain
on Heart
Hyperlipidemia
Sleep apnea
Weight Loss
Restricted Food
Low
Body
Fat
Weight Loss
Less Strain on Respiratory System
Improve
Sleep Breathing
Restricted food
Limit Sodium Amount
(Bryn Mawr Hospital, 2015)
Hydration
Very Important
Body is losing weight and fluids
Fluids should be compensated by the intke of water or any low calorie fluids.
Fluids should be taken between meals and snacks to avoid dumping syndrome.
At least eight cups of fluid daily to avoid any dehydration.
(UCSF Medical Center, 2015)
Calcium
Calcium is absorbed in duodenum.
Gastric acid aids absorption.
Stomach & duodenum bypassed by surgery, which causes reduced calcium absorption.
Calcium deficiency leads to osteoporosis.
Vitamin B12
Vitamin B12 is absorbed in ileum.
Vitamin B12 needs intrinsic factors to be absorbed.
Intrinsic factors is produced in stomach, which is bypassed.
So no intrinsic factor is produced, no absorption of vitamin B 12.
Vitamin B12 deficiency causes anemia and affects the nerves.
(Johnson, 2014)
Protein
Less protein intake due to reduced stomach capacity.
Protein is needed to fasten the healing process, and to maintain lean body mass.
Protein dense food should be eaten
Low amounts will provide satiety
Prevent any muscle breakdown

Protein malnutrition leads to edema and nutrients deficiencies.

(Morley, 2014)
Iron
Iron absorption in duodenum.
Gastric acid aids in iron absorption.
Stomach & duodenum bypassed by surgery, which causes iron malabsorption.
Iron deficiency will lead to anemia.
(Bowen, 2008)
(Bowen, 2008)
(“Your diet after gastric bypass surgery”, 2012)
After reading the physician’s history and physical, identify any signs or symptoms that are most likely a consequence of Mr. McKinley’s morbid obesity.
Identify the pertinent nutrition problems and the corresponding nutrition diagnoses.
Question 14:
Determine the appropriate progression of Mr. McKinley’s post-bariatric surgery diet. Include recommendations for any supplementation that you would advise.
Question 15:
Describe any pertinent lifestyle changes that you would view as a priority for Mr. McKinley.
Question 16:
How would you assess Mr. McKinley’s readiness for a physical activity plan? How does exercise assist in weight loss after bariatric surgery?
Question 17:
Identify the steps you would take to monitor Mr. McKinley’s nutritional status post-operatively.
Question 18:
From the literature, what is the success rate of bariatric surgery? What patient characteristics may increase the likelihood for success?
Question 19:
· Obesity due to sedentary lifestyle, excess body weight, and intake of food.

· Type 2 diabetes mellitus due to insulin resistance because of body fat; fat inhibits insulin from binding to the receptors, and also because of family medical history.

· Hypertension due to strain on heart from fat, and partially blocked arteries causes pressure to build up so that the blood can pass through the vessel.

· Hyperlipidemia due to high body fat, and high lipids in blood that blocks the arteries some times.

·Osteoarthritis due to the strain caused to the knee from the excess body weight.
Phase 1: Clear Liquid Diet (Day 1 -4)
Phase 2: Full Fluid Diet (Week 1- 2)
Phase 3: Pureed Diet (Week 3- 4)
Phase 4: Soft Diet (Week 5- 6)
Phase 5: Regular Diet (Week 7 and after)
Small meals, 3 – 4 meals per day
Consume protein rich food to heal wounds properly, and maintain lean muscle mass while weight loss.
Consume fruits and vegetables that will provide fiber and antioxidants. They have to be chewed well and cut into small pieces if they contain skin.
Consume whole grains that will provide fiber, vitamins and minerals.
Limit amount of fat consumed; choose unsaturated rather than saturated fat.
Include protein shakes as snacks to provide the extra protein needed for the body.
Limit amount of sugary food or drinks to minimize dumping syndrome effect.
Vitamins and minerals supplements needed
Soft moist cooked food, no raw food.
Similar to pureed diet but food can be soft and cooked well.
Food such as: well cooked vegetables, cooked soft chicken or fish, soft cheese, minced ground meat, and canned soft fruits.
Avoid nuts and seeds
3 -4 meals per day.
Blended pureed food that is easily swallowed and chewed
Include 1-2 ounces pureed protein food, and 1 ounce pureed vegetable
Small, frequent meals. 5-6 meals per day.
Drink liquids 30 minutes after meals.
Add protein drinks to diet. Can add protein powder to any drink. Drink protein shakes.
Eat in small plates to eat smaller amounts; use utensils.
Around ½ cup of food per meal.
Pureed food such as: egg whites, pureed beans, pureed fish or meat, and pureed soft fruits without skin.
Sip fluids slowly.
Drink at least 4 cups of water per day.
Increase amount of fluid to 4-6 fluid ounces per meal. Have a meal every hour at least.
Add protein drinks to diet. Can add protein powder Blended, strained, liquid fluids same consistency of milk. Fluids such as: vegetable juice, fat free milk, sugar free pudding, sugar free fat free yogurt, and diluted juice.
Sugar free clear liquid should be taken only.
Small, frequent meals. 0.5 fluid ounce to 1 fluid ounce per meal should be taken. Every 15 to 30 minutes.
Sip liquids slowly without using straws.
Fluids such as, water, diluted unsweetened juice, clear broth, and sugar free gelatin.
Daily Physical activity
Maintaining weight loss
Improve health

Change type of food consuming
Sweets should be avoided to prevent dumping syndrome

Eat small, few meals.
Learn to stop eating when feeling full, to avoid any nausea or vomiting.
Daily vitamins and minerals supplement
· Assess if Mr. McKinley is willing to physical activity, by setting small, realistic, and manageable goals, such as walking at least for 15 minutes a day.

· Find a physical activity that he enjoys doing, or chooses an activity that will make him move that he enjoys.

· Low to moderate activities can be done when healing is complete, but before the completion of healing he can walk a little bit.

· Physical activity will help maintain the weight Mr. McKinley lost after the surgery. Also, it will help in reducing the chronic conditions he has, such as type 2 diabetes, and hypertension.

· Mr. McKinley should always follow up with a physician in case of any pain or injuries after physical activity.
· Assess energy needs and adjust according to the expanding of the stomach. Energy needs should be calculated to body needs, and it should be assessed by a 24 hour recall to monitor patients progress.

· Assess hydration status, make sure the patient is consuming at least eight cups of fluids daily to prevent dehydration. Also, make sure the patient is consuming fluids between meals to avoid dumping syndrome.

· Assess sugar intake, since the patient is diabetic and to avoid dumping syndrome. Assess blood sugar levels to maintain the blood glucose, keep records of blood glucose tests to see improvement

· Assess lipid levels in blood to see improvements in cholesterol and triglycerides after weight loss.

· Assess potassium level, since the patient had high level before the surgery. Any sudden change in potassium might affect the heart.

· Assess weight loss per week, to keep track of the weight the patient is losing after the surgery.

· Assess vitamin and minerals in body, and give supplements, since the surgery is restrictive malabsorptive, some minerals and vitamins might not be absorbed and there will be deficiencies
Mr. McKinley asks you about the possibility of bariatric surgery for a young cousin who is 10 years old. What are the criteria for bariatric surgery in children and adolescents?

Question 20:

· Patients usually lose about 38% of total body
weight in 1-2 years.

· 90% of patients saw improvement in type 2
diabetes.

· Improvement of obesity related health
conditions such as hypertension, and sleep
apnea.


Success Rate of Bariatric Surgery:
Patient characteristics that may increase likelihood for success:

· Willing to commit to lifestyle changes.

· Willing to incorporate physical activity in
routine
(Sanford Health, 2014)

· Severe obesity: BMI > 40 kg/m2 with severe comorbid
conditions, such as diabetes type II, sleep apnea, and
hypertension. Or BMI > 50 kg/m2 with less severe
comorbid conditions.

· Failed to loss weight for more than six months, under the
observation of a physician.

· Have attanied skeletal maturity
( Girls: age 13, Boys: age 15)

· Willing to commit to the nutritional guidelines, and
lifestyle changes after the surgery.

·Able to make decisions.
Criteria for bariatric surgery in children and adolescents:
Full transcript