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Top 10 Things You Need to Know About Bariatric Surgery

Patients' overall food intake had declined since before surgery, except for fluids, dairy products, and sweet foods. Fruit and vegetable consumption had declined the most, and then meat, fish, and complex carbohydrates. The authors of the study questioned whether the patients' relatively unhealthy diets might eventually counterbalance the benefits of weight loss.

Extended-release formulations that are designed to remain in the intestine for long periods may not be absorbed as well or according to the expected time course []. Immediate-release formulations are generally recommended in these patients; however, healthcare providers are not always aware of recommended vitamin regimens, dosages, and appropriate formulations. Daily multivitamin, calcium, iron, vitamin B12, and folic acid supplementation were evaluated.

Inappropriate formulations e. Fifty percent of patients were discharged with inappropriate formulations []. Although medication absorption in bariatric surgery patients is not well studied, the reduction in acid due to structural changes in the stomach may alter absorption of medications that require an acidic environment. More pharmacokinetic clinical studies are needed to address the specific effects of various bariatric procedures on drug absorption [].

Beyond information about nutrition, day-to-day life after bariatric surgery is rarely addressed in the literature. To help illuminate patients' experiences following these procedures, Potoczna and colleagues reported on bowel habits after gastric banding, RYGB, and BPD []. Compared with before surgery, patients who had adjustable gastric banding were more likely to report increased constipation at three or more months after surgery. RYGB patients were also more likely to report malodorous flatus, to be bothered by it, and to feel that their social life was affected.

A similar pattern was seen with BPD. For both RYGB and BPD, severity of flatus was inversely correlated with quality of life subscores on the bariatric analysis reporting outcome system scale. However, some patients will be able to lose weight and keep it off through increased physical activity and healthier eating.

The U. Counseling may address diet, exercise, or both, and behavioral interventions may be aimed at skill development, motivation, and support. Some patients will struggle to lose this amount of weight, while others will be able to lose substantially more. Some patients will benefit from pharmacotherapy to aid in weight loss. The European Medicines Agency guideline requirements are similar. Both agencies also call for evidence of improvements in metabolic comorbidities [].

Weight loss achieved through the use of medication tends to be modest, and weight is often regained when the drugs are stopped [, , ]. Orlistat inhibits nutrient absorption. Orlistat has been shown to increase weight loss and improve cardiovascular risk factors. Primary side effects are gastrointestinal discomfort and a decrease in absorption of fat-soluble vitamins [].


  • Learning for Leadership: Building a School of Professional Practice (Educational Leadership Dialogues).
  • Complication rates lower for white versus black patients?
  • 1. Introduction;
  • Guiding the non-bariatric surgeon through complications of bariatric surgery - EM|consulte?

Independent reports of liver injuries including six cases of liver failure between and prompted the FDA to approve a label revision for orlistat that includes a warning of possible severe liver injury []. However, the risk of severe liver injury is low, and this risk should be weighed against potential benefits []. Orlistat is indicated for the treatment of obesity in conjunction with a reduced-calorie diet []. A woman with BMI of 36 who states that she wants the surgery because "I can't seem to control what I eat.

Mortality rates are generally lower in hospitals that do a high volume of bariatric surgeries than at those with lower numbers. There was no difference between surgery patients and controls in terms of recovery from hypercholesterolemia at 2 or 10 years. There was no difference between surgery patients and controls in terms of recovery from hypertriglyceridemia at 2 or 10 years. Mortality after bariatric surgery is greater than that of obese patients who did not choose surgery, but quality of life is better.

Compared with matched controls, bariatric surgery patients are less likely to die from diabetes but more likely to die from accidents or suicide. Compared with matched controls, bariatric surgery patients were less likely to die from diabetes but more likely to die from cardiovascular disease. Nutritional deficiencies do not occur with purely restrictive procedures, and no supplements are needed. Vitamin D deficiency is rare after bariatric surgery because it is not preferentially absorbed in the duodenum and jejunum. Extended-release medications should generally be used instead of immediate-release formulations.

Reduction in stomach acid due to structural changes may alter absorption of some medications. The Physical Activity Guidelines for Americans recommends minutes of moderate-intensity aerobic activity per week. To meet current exercise recommendations, patients must do 30 consecutive minutes of moderate exercise 7 days per week. As a general rule, obese patients should be advised to reduce their caloric intake by calories per day in order to lose 1 to 2 pounds per week. Rates of serious complications are inversely associated with hospital and surgeon procedure volume, but unrelated to COE accreditation by professional organizations.

With rates increasing over the last decade, 1 bariatric surgery has become the second most common abdominal operation in the United States. Despite trends toward declining mortality rates, 2 payers and patient advocacy groups remain concerned about the safety of bariatric surgery and uneven quality across hospitals.

In response, 2 major professional organizations—the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery—have implemented programs for accrediting hospitals as centers of excellence COE in bariatric surgery. Standards for COE accreditation vary somewhat between the programs, but they generally include minimum procedure volume standards, availability of specific protocols and resources for managing morbidly obese patients, and submission of outcomes data to a central registry.

Whether COE accreditation helps patients and payers identify safer hospitals for bariatric surgery remains a matter of debate. Hospital procedure volume, a core component of accreditation, has been linked to perioperative mortality with bariatric surgery. As bariatric surgery has been more commonplace and mortality has declined, previous hospital volume benchmarks per year for COEs may be less important now than in the past. To date, only 1 published study has directly compared the outcomes of bariatric surgery at COE and non-COE hospitals, noting higher mortality and equivalent morbidity at the former.

It also included data from only 1 year, , when COE programs were just beginning to be implemented. In this context, we studied perioperative outcomes at 25 hospitals participating in the Michigan Bariatric Surgery Collaborative MBSC , a payer-funded quality improvement program that administers a prospective, externally audited clinical outcomes registry.

In addition to comparing complication rates by procedure and among hospitals, we examined relationships between procedure volume, COE accreditation, and hospital safety. This study is based on analysis of data from the MBSC. As described in greater detail elsewhere, the MBSC is a regional consortium of hospitals and surgeons performing bariatric surgery in Michigan.

The MBSC now enrolls approximately patients per year from 25 hospitals in its clinical registry. Participating hospitals submit data for all of their bariatric surgery patients including those undergoing gastric bypass, laparoscopic gastric banding, biliopancreatic diversion with or without duodenal switch, and sleeve gastrectomy procedures.

Procedures done on an outpatient basis are included in the MBSC registry and are subject to the same data collection requirements. In the MBSC, data for the clinical registry is collected via medical record review for each patient at the end of the day perioperative period. Information collected includes demographic variables, preoperative clinical characteristics and conditions, as well as perioperative process of care and outcomes. Patient readmissions to other hospitals are captured if it is recorded in the medical records of the hospital performing the bariatric surgery.

The medical record reviews are performed by centrally trained nurse data abstractors using a standardized and validated instrument. Each participating hospital is visited annually by the project data quality coordinator to verify the accuracy and completeness of its MBSC clinical registry data. The collection of data for the purposes of participation in the MBSC has been approved by the institutional review boards of all member sites.

We excluded patients undergoing revisional surgery from this analysis because of the heterogeneity of the patient population and surgical procedures as well as inherently higher rates of complications for patients undergoing revisional surgery. Data were collected on 12 different types of bariatric surgery—related complications.

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Complications were grouped according to severity as non—life-threatening, potentially life-threatening, or life-threatening complications associated with residual and permanent disability or death. Complications resulting in permanent disability included myocardial infarction or cardiac arrest, renal failure requiring long-term dialysis, respiratory failure requiring more than 7 days of intubation, or tracheostomy.

The MBSC end points committee grades the severity of any perioperative complications not falling unambiguously into one of these categories. Our primary outcome measure for this study was the occurrence of a serious complication defined as potentially life threatening or resulting in death or disability. Data on patient characteristics include patient demographics, weight and medical history, and weight-related and other comorbidities listed in Table 1.

In general, MBSC comorbidity definitions include clinical documentation of the condition, its treatment, or both in the medical record. Cardiovascular disease includes coronary artery disease, heart rhythm disorder, congestive heart failure, or peripheral vascular disease. Patients with nonalcoholic fatty liver, clinical or subclinical cirrhosis, or liver transplant are considered to have liver disorders. Annual hospital and surgeon volume categories Table 2 were determined using a combination of generally accepted volume cut points and empirical derivation based on the distribution of patients, hospitals, and surgeons.

Sites were deemed centers of excellence if they were designated as such by the American College of Surgeons or the American Society of Metabolic and Bariatric Surgeons at any point during our study period. Multilevel mixed-effects logistic regression models were used to evaluate risk factors for serious complications, with the log odds of the outcome modeled as a linear function of baseline covariates. The final models included all patient risk factors that were significant in multivariate analyses age, body mass index [calculated as weight in kilograms divided by height in meters squared], male sex, mobility limitations, prior history of venous thromboembolism, and total number of comorbid conditions and procedure type laparoscopic adjustable gastric band, sleeve gastrectomy, or gastric bypass as fixed effects, and hospital identifier as a random effect to adjust for clustering of patients within hospitals.

Because hospital and surgeon complication rates can vary due to chance alone, we adjusted our estimates for reliability. This technique adjusts hospital and surgeon outcomes for random variation, ensuring that performance is not overestimated or underestimated due to statistical noise.

Reliability is measured on a scale of 0 completely unreliable to 1 perfectly reliable and is largely a function of sample size. For this analysis, we used the random effects from the mixed-effects models to calculate risk- and reliability-adjusted complications rates for each hospital.

For this calculation, we add the overall average log odds of serious complications to the random effect since the mean is 0 by definition and then take the inverse logit of this sum. All statistical analyses were performed using Stata version There were significant differences across the procedure types with regard to all potential risk factors for complications, including demographics, medical history, and obesity-related comorbidity Table 1.

In general, patients receiving laparoscopic adjustable gastric bands were lower risk than patients receiving gastric bypass or sleeve gastrectomy. Specifically, patients receiving laparoscopic adjustable gastric bands had significantly lower body mass index at baseline and lower rates of associated comorbid conditions.

Internal hernia

The predicted risk of serious complications based on a logistic regression model including significant multivariate predictors age, body mass index, male sex, mobility limitations, prior history of venous thromboembolism, and total number of comorbid conditions was 2. Overall, 7. Rates of potentially life-threatening complications Table 3 were highest for patients undergoing gastric bypass 3. Fatal complications occurred in 2 patients receiving laparoscopic adjustable gastric band 0.

Complications that were not fatal but that resulted in permanent disability occurred in 2 patients receiving laparoscopic adjustable gastric band 0. Complications at the surgical site occurred in 5. Infection was the most frequent type of complication 3. The subcategory of medical complications including venous thromboembolism, cardiac, renal failure, and respiratory occurred in 1. Rates of reoperation ranged from 0. Transfers to other medical facilities 0. Rates of both readmission and emergency department visits were lowest in patients who received laparoscopic adjustable gastric band and highest in those receiving gastric bypass.

Median hospital length of stay days was 1 range, , 2 range, , and 2 range, for patients receiving laparoscopic adjustable gastric band, sleeve gastrectomy, and gastric bypass, respectively. Risk- and reliability-adjusted rates of serious complications varied from 1. Rates were significantly lower than the statewide average for 3 hospitals. Risk of serious complications was inversely associated with average annual bariatric procedure volume Table 2.

For surgeon volume, rates in the low-, medium-, and high-volume categories were 3. For hospital volume, adjusted rates of serious complications were 4. A study indicated that Anatomical changes are likely not the only cause of nutritional deficiencies after bariatric surgery.

Probing problems with bariatric surgery: Reoperations, variation are common

The ASMBS guideline notes that purely restrictive surgeries, while once thought not to be associated with nutritional deficiencies, may in fact lead to deficiencies due to poor diet and food intolerance. Research on dietary habits after a restrictive procedure reinforces this concern, as demonstrated in a case study of consecutive patients in one surgical ward who had undergone VBG, a restrictive surgery, between and []. Sixty-two percent of eligible patients participated, and the average time of follow-up after surgery was 5.

Patients' overall food intake had declined since before surgery, except for fluids, dairy products, and sweet foods. Fruit and vegetable consumption had declined the most, and then meat, fish, and complex carbohydrates. The authors of the study questioned whether the patients' relatively unhealthy diets might eventually counterbalance the benefits of weight loss. Extended-release formulations that are designed to remain in the intestine for long periods may not be absorbed as well or according to the expected time course [].

Immediate-release formulations are generally recommended in these patients; however, healthcare providers are not always aware of recommended vitamin regimens, dosages, and appropriate formulations.

Bariatric Surgery Procedures | ASMBS

Daily multivitamin, calcium, iron, vitamin B12, and folic acid supplementation were evaluated. Inappropriate formulations e. Fifty percent of patients were discharged with inappropriate formulations []. Although medication absorption in bariatric surgery patients is not well studied, the reduction in acid due to structural changes in the stomach may alter absorption of medications that require an acidic environment.

More pharmacokinetic clinical studies are needed to address the specific effects of various bariatric procedures on drug absorption []. Beyond information about nutrition, day-to-day life after bariatric surgery is rarely addressed in the literature. To help illuminate patients' experiences following these procedures, Potoczna and colleagues reported on bowel habits after gastric banding, RYGB, and BPD []. Compared with before surgery, patients who had adjustable gastric banding were more likely to report increased constipation at three or more months after surgery.

RYGB patients were also more likely to report malodorous flatus, to be bothered by it, and to feel that their social life was affected. A similar pattern was seen with BPD. For both RYGB and BPD, severity of flatus was inversely correlated with quality of life subscores on the bariatric analysis reporting outcome system scale.

However, some patients will be able to lose weight and keep it off through increased physical activity and healthier eating. The U. Counseling may address diet, exercise, or both, and behavioral interventions may be aimed at skill development, motivation, and support. Some patients will struggle to lose this amount of weight, while others will be able to lose substantially more.

Some patients will benefit from pharmacotherapy to aid in weight loss. The European Medicines Agency guideline requirements are similar. Both agencies also call for evidence of improvements in metabolic comorbidities []. Weight loss achieved through the use of medication tends to be modest, and weight is often regained when the drugs are stopped [, , ].

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Orlistat inhibits nutrient absorption. Orlistat has been shown to increase weight loss and improve cardiovascular risk factors. Primary side effects are gastrointestinal discomfort and a decrease in absorption of fat-soluble vitamins []. Independent reports of liver injuries including six cases of liver failure between and prompted the FDA to approve a label revision for orlistat that includes a warning of possible severe liver injury [].

However, the risk of severe liver injury is low, and this risk should be weighed against potential benefits []. Orlistat is indicated for the treatment of obesity in conjunction with a reduced-calorie diet []. A woman with BMI of 36 who states that she wants the surgery because "I can't seem to control what I eat. Mortality rates are generally lower in hospitals that do a high volume of bariatric surgeries than at those with lower numbers. There was no difference between surgery patients and controls in terms of recovery from hypercholesterolemia at 2 or 10 years.

There was no difference between surgery patients and controls in terms of recovery from hypertriglyceridemia at 2 or 10 years. Mortality after bariatric surgery is greater than that of obese patients who did not choose surgery, but quality of life is better. Compared with matched controls, bariatric surgery patients are less likely to die from diabetes but more likely to die from accidents or suicide.

Compared with matched controls, bariatric surgery patients were less likely to die from diabetes but more likely to die from cardiovascular disease. Nutritional deficiencies do not occur with purely restrictive procedures, and no supplements are needed. Vitamin D deficiency is rare after bariatric surgery because it is not preferentially absorbed in the duodenum and jejunum.