About this course:
The purpose of this course is to review the incidence of obesity in the US and discuss the benefits and risks of various bariatric surgical options. Additionally, the course will examine the criteria for bariatric surgery clearance and discuss the preoperative and postoperative care of bariatric patients, including complications that can occur with bariatric surgery.
The purpose of this course is to review the incidence of obesity in the US and discuss the benefits and risks of various bariatric surgical options. Additionally, the course will examine the criteria for bariatric surgery clearance and discuss the preoperative and postoperative care of bariatric patients, including complications that can occur with bariatric surgery.
Upon completion of this activity, learners should be able to:
- explore the incidence and prevalence of obesity in the US
- describe the benefits and risks of various bariatric surgical options for obesity
- identify the criteria for bariatric surgery clearance
- discuss preoperative and postoperative care of bariatric patients
- describe the complications that can occur with bariatric surgery
- discuss the short- and long-term effects of bariatric surgery
Obesity impacts an increasing number of people worldwide, and the US ranks 12th in the world in the prevalence of obesity. Chronic diseases associated with obesity include obstructive sleep apnea (OSA), type 2 diabetes, dyslipidemia, nonalcoholic fatty liver disease, hypertension, orthopedic complications, cardiac disease, stroke, and infertility. Weight loss programs, diets, medications, and other therapeutic interventions are frequently unsuccessful in reversing obesity and, even where successful, rarely provide long-term weight maintenance. Bariatric surgery was introduced in the 1950s at the University of Minnesota as an option for weight loss and has continued to increase in prevalence with innovative technology and advancements in surgical options over the last few decades. Bariatric surgery continues to be the most sustainable and effective treatment for obesity in the US, offering the most lasting effects on decreasing chronic disease and mortality for patients with obesity (Albaugh & Abumrad, 2018; American Society of Metabolic and Bariatric Surgical Procedures [ASMBS], n.d.; World Population Review, 2022).
Incidence and Prevalence
More than 2.1 billion people worldwide are considered obese, with approximately 93 million living in the US. A person is considered obese when their body mass index (BMI) is 30 or higher; a normal BMI is 18.5 to 24.9. A person's BMI is calculated using their weight in kilograms divided by the square of their height in meters. A high BMI is associated with various metabolic and disease outcomes. From 2005 to 2008, obesity rates in the US went up by 13.9% for adults ages 20 and over. In 2008, the US Healthy People 2010 health initiatives established targets to increase physical activity, and aerobic and muscle-strengthening exercise increased in adults by 31.9%. However, obesity rates increased during the same timeframe. From 2013 to 2016, obesity continued to rise. Thus, an increase in activity overall for the population did not lead to a decrease in overall obesity (Office of Disease Prevention and Health Promotion [ODPHP], 2022). According to the Centers for Disease Control and Prevention (CDC), adult obesity rates from 1999 through 2020 have increased from 30.5% to 41.9%, with severe obesity (BMI over 40) rates rising from 4.7% to 9.2%. In 2019, the annual medical cost for obesity care was nearly $172 billion. The average healthcare cost for adults with obesity is $1,861 more than for adults who are not obese. Worldwide, over 3 billion people die annually due to obesity and its complications. This rate has tripled over the past 40 years. Moreover, a person's health and quality of life are significantly impacted by obesity for years before death in most cases. In addition to the health problems previously mentioned, there is an increased risk of cancer, sleep disorders, kidney disease, and diminished mobility related to obesity (CDC, 2022a, 2022b; World Population Review, 2022).
Bariatric Surgery Options
There are various types of bariatric surgeries, which are often referred to as weight-loss surgery. All bariatric surgeries limit the amount of food consumed, thereby promoting weight loss. Bariatric surgeries can be divided into restrictive and malabsorptive procedures. Malabsorptive procedures decrease caloric, protein, and other nutrient absorption by shortening the absorption length of the functional small intestine. A procedure called biliopancreatic diversion falls within this category. Restrictive surgeries limit the amount of food a patient can consume and promote a feeling of fullness (i.e., satiety) after eating. This restriction is accomplished by reducing the stomach's reservoir capacity via bypass, resection, or creating a proximal gastric outlet. Restrictive surgeries include the sleeve gastrectomy and gastric banding or the lap band. The Roux-En-Y procedure combines both mechanisms. The most common procedures include gastric bypass, sleeve gastrectomy, adjustable gastric band, and biliopancreatic diversion with a duodenal switch. Strict adherence to a postoperative diet is required with all procedures, and strict follow-up visits with healthcare providers (HCPs) are necessary (ASMBS, 2021; Lim, 2022b; National Institute of Diabetes and Digestive and Kidney Diseases [NIDDK], 2020a).
The gastric bypass procedure was initially developed in the 1960s and has evolved into its current form, the Roux-En-Y gastric bypass. It is among the most commonly performed weight loss procedures in the US. However, global trends showed an overall decline in bariatric surgeries from approximately 65% in 2003 to 47% in 2011. This surgery creates a small pouch from the stomach and connects it to the small intestine. This procedure causes ingested food to go directly into the small intestine and bypasses the majority of the stomach and the initial portion of the small intestine, limiting the absorption of food and facilitating weight loss. The rerouting of food into the small intestine creates a change in gut hormones that promotes satiety and suppresses hunger. Additionally, this process reverses the primary mechanism in which obesity induces type 2 diabetes (ASMBS, 2021; Lim, 2022b; NIDDK, 2020a). For a graphic depiction of the surgical process of the gastric bypass, see Figure 1.
Advantages of the gastric bypass procedure include:
- significant long-term weight loss: typically, 60%-80% of excess body weight (EBW)
- improved overall health, thereby increasing energy expenditure and activity
- reduced appetite and improved satiety through changes to gut hormones
- overall maintenance that is typically greater than 50% of the weight initially lost (ASMBS, 2021; Lim, 2022b; NIDDK, 2020a)
Disadvantages of the gastric bypass procedure include:
- procedural complexity and associated complications
- long-term vitamin and mineral deficiencies, including iron, calcium, folate, and B12
- longer recovery time and hospital stay than other procedures
- strict dietary adherence required for the remainder of life, including vitamin and mineral supplementation
- follow-up for compliance with dietary adherence (ASMBS, 2021; Lim, 2022b; NIDDK, 2020a)
Sleeve gastrectomy is completed laparoscopically and removes approximately 80% of the stomach. The remaining stomach is tubular-shaped, resembling a banana. With a limited stomach size, the amount of food that can be consumed is considerably decreased, thereby prompting weight loss. Hormonal chan
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Advantages of the sleeve gastrectomy procedure include:
- rapid and substantial weight loss similar to the Roux-En-Y gastric bypass
- weight loss maintenance is typically greater than 50% of initial weight over 3 to 5 years and comparable to Roux-En-Y gastric bypass maintenance
- no bypass of the food stream (as in the Roux-En-Y gastric bypass) and no foreign object (as in the adjustable gastric band)
- short recuperation and hospital stay (typically 2 days)
- changes in gut hormones improve satiety, decrease appetite, and suppress hunger (ASMBS, 2021; Lim, 2022b; NIDDK, 2020a; Seeras et al., 2022)
Disadvantages of the sleeve gastrectomy procedure include:
- non-reversible surgery
- a higher early complication rate than the adjustable gastric band
- potential for long-term vitamin deficiencies (ASMBS, 2021; Lim, 2022b; NIDDK, 2020a; Seeras et al., 2022)
Adjustable Gastric Band
The adjustable gastric band—lap band or "the band," as it is often called—utilizes an inflatable band placed around the upper portion of the stomach to create a small pouch above the band, leaving the residual stomach below the band. The device limits the amount of food that can be ingested. The pouch becomes full quickly, and hunger is satisfied. The pouch size can be adjusted by filling the band with sterile saline injected via a port placed under the skin. The pouch size is decreased over time with repeated injections into the port. There is no malabsorption of food with this procedure. This procedure can be reversed in most cases. Due to a high rate of complications or failure, this procedure is rarely done in the US anymore (ASMBS, 2021; Lim, 2022b; NIDDK, 2020a). The adjustable gastric band procedure is shown in Figure 3.
Advantages of the adjustable gastric band procedure include:
- weight loss of 40% to 50% of EBW that, while less than other procedures, is significant for most individuals
- no incision within the stomach or rerouting of the intestines
- reversible and adjustable
- the lowest rate of early postoperative complications and mortality among all bariatric procedures
- the lowest risk of vitamin or mineral deficiencies of all bariatric procedures (ASMBS, 2021; Lim, 2022b; NIDDK, 2020a)
Disadvantages of the adjustable gastric band procedure include:
- slower weight loss than other bariatric procedures
- decreased early weight loss compared to other bariatric procedures
- foreign device implantation
- potential for the band to migrate, erode into the stomach, or develop mechanical problems, including tube or port malfunctions
- risk of esophageal dilation (expansion of the tissue), dysmotility (lack of movement), or esophagitis (inflammation) if the patient overeats
- the highest rate of re-operation of all bariatric procedures secondary to complications (ASMBS, 2021; Lim, 2022b; NIDDK, 2020a)
Biliopancreatic Diversion with Duodenal Switch
A biliopancreatic diversion with duodenal switch is the least common weight loss surgery discussed in this module. This surgery involves two steps, starting with a sleeve gastrectomy. As described above, approximately 80% of the stomach is removed, and a banana-shaped tubular stomach is created. The pyloric sphincter also remains, which allows food to pass into the small intestine. The second part of the surgery bypasses most of the small intestine. During this procedure, the duodenum (first portion of the small intestine) is divided just past the pyloric sphincter. The lower portion of the small intestine is then connected to the outlet of the newly created stomach pouch. When the patient eats, food goes through the tubular stomach and empties directly into the lower portion of the small intestine, bypassing about 75% of the small intestine. Consequently, food does not mix with the natural pancreatic enzymes or bile until it is further along in the small intestine, resulting in decreased absorption of nutrients and calories (ASMBS, 2021; Lim, 2022b; NIDDK, 2020a). This procedure is depicted in Figure 4.
Advantages of the biliopancreatic diversion with duodenal switch procedure include:
- weight loss of 60% to 70% of EBW or higher at the 5-year follow-up, which is higher than with other bariatric surgeries
- potential for patients to eat more "normal" meals after a few months
- enhanced gut hormones to reduce appetite and improve satiety
- most effective at reducing the rate of type 2 diabetes in comparison to other bariatric surgeries
- reduced-fat absorption (up to 70%) due to delayed pancreatic enzyme activity (ASMBS, 2021; Lim, 2022b; NIDDK, 2020a)
Disadvantages of the biliopancreatic diversion with duodenal switch procedure include:
- a higher complication rate and increased mortality risk with this procedure than with other bariatric surgeries
- greater potential for vitamin and mineral deficiencies than with other procedures
- a more extended hospital stay after surgery compared to gastric bypass or gastric band procedures
- compliance with diet and follow-up visits are crucial with this procedure to avoid serious complications from protein and vitamin deficiencies (ASMBS, 2021; Lim, 2022b; NIDDK, 2020a)
Benefits and Risks of Bariatric Surgery
Evidence regarding the benefits of weight loss surgery dates back to the 1960s. The last few decades have been accompanied by a significant rise in weight-loss surgeries as an increase in obesity has occurred. Numerous studies have found that all bariatric procedures provide better long-term weight management than non-surgical weight loss options such as diet, exercise, or other supportive services (e.g., weight loss programs). Compared to conventional weight-loss methods, there is a decreased risk of mortality and morbidity for patients with severe obesity after bariatric surgery. In addition, the weight loss associated with bariatric surgery leads to reduced rates of OSA, osteoarthritis, stress incontinence, dyslipidemia, hypertension, coronary artery disease, acute cardiovascular events, type 2 diabetes, obesity-related cancers, and death. For individuals with severe obesity, weight loss surgery can extend their life by years (Albaugh & Abumrad, 2018; ASMBS, 2021; NIDDK, 2020b).
The risks associated with bariatric surgeries can involve complications related to general anesthesia. Immediate postoperative complications include bleeding, infection, diarrhea, deep venous thrombosis (DVT), bowel obstruction, and perforation. Long-term complications involve ulcerations from the gastric band or nutritional deficits from the lack of absorption associated with all bariatric procedures. Nutrient deficiencies can lead to anemia and osteoporosis. Rapid weight loss can also increase the risk of gallstones because it can alter the balance of cholesterol, lecithin, and bile acids, preventing the gallbladder from emptying adequately (Albaugh & Abumrad, 2018; ASMBS, 2021; Crossan & Sheer, 2022b; NIDDK, 2020c).
Criteria for Bariatric Surgery Clearance
Bariatric surgery is not recommended for all patients and can be costly. Patients considering bariatric surgery should be counseled to contact their health insurance company directly to determine coverage and discuss payment options with their HCP's billing department for any costs not covered by their health insurance. Furthermore, the physical, mental, and social aspects of the surgery require providers to conduct extensive screening processes to clear a patient for the procedure. Generally, these procedures are considered for anyone with a BMI over 40 or a BMI between 35 and 39, along with comorbidities such as severe OSA, hypertension, type 2 diabetes, or other serious weight-related health problems. Occasionally, a patient with a BMI between 30 and 34 may be considered if serious weight-related health problems are present. Candidate approval for bariatric surgery should be based on prior weight loss attempts, the presence and severity of comorbidities, overall health status for surgery consideration, and the ability to comply with preoperative and postoperative instructions. A complete assessment focusing on comorbidities such as cardiac and respiratory concerns can create a safer environment for intraoperative care. In addition, closer postsurgical monitoring may be required for those with identified risks before surgery (ASBMS, 2021; Lim, 2022a; Schlottman et al., 2018; Stahl, 2022).
Medical clearance for bariatric surgery should include a thorough history that explores the patient's weight history, dietary history, social history, psychological history (particularly eating disorders, physical abuse, or substance abuse), physical activity, review of medications, and psychosocial behaviors/factors that might impact weight loss or future success due to non-adherence. The clinical examination should include assessments of laboratory values, including electrolytes, vitamins, iron, folate, calcium, a basic metabolic panel (BMP), a complete blood count (CBC), and a lipid profile. Patients with type 2 diabetes should achieve glycemic control before surgery, thus decreasing their risk of postoperative complications (Lim, 2022a; Schlottman et al., 2018; Stahl, 2022).
Since cardiac complications often co-exist with obesity, stabilizing all comorbidities before surgery is vital to prevent postoperative complications. All patients evaluated for bariatric surgery should have a 12-lead electrocardiogram (ECG), followed by a cardiac stress test, either with a treadmill or scintigraphic imaging. These may not be possible for patients with morbid obesity due to the weight limitations of testing equipment, difficulty in accurately interpreting images due to body habitus, and each patient's physical capabilities. For these patients, pharmacological stress testing may be done with or without ultrasound contrast agents to determine cardiac function as accurately as possible (Lim, 2022a; Schlottman et al., 2018; Stahl, 2022).
Airway complications are prevalent in patients with severe obesity due to mechanical restriction. Preoperative pulmonary function testing may help identify patients at high risk for pulmonary complications following the surgery. Screening tools such as the Stop, STOP-BANG (snoring, tired, observed, pressure, body mass index, age, neck size, and gender), Epworth Sleepiness Scale (ESS), or 4-Variable screening tool (4-V) are available to help identify patients at risk for OSA. Patients who are identified as at risk for OSA during this preoperative testing should be referred for evaluation with overnight polysomnography (sleep study) and may need to begin treatment with a continuous positive airway pressure (CPAP) machine during sleep. Patients who present with daytime hypercapnia, also known as obesity hypoventilation syndrome (OHS), may also benefit from CPAP therapy or bi-level positive pressure (Bi-Pap) preoperatively. Routine spirometry testing may be done for those with a high risk of pulmonary complications, and preoperative optimization with a pulmonologist may be warranted to improve patient outcomes during and after the surgery (Lim, 2022a; Schlottman et al., 2018; Singh & Mins, 2015; Stahl, 2022).
Preoperative psychological evaluation and clearance are significant to patient success post-surgery. The long-term outcomes of surgery are based on each patient's ability to follow a strict postoperative diet and lifestyle regimen. This evaluation will also prepare the patient for possible emotional adjustments as their weight is reduced. A comprehensive behavioral assessment should include a history of any eating or behavioral disorders, any current or history of anxiety or mood disorders, all current or past mental health conditions or treatments, and an evaluation of the patient's motivation for weight loss. Perhaps more important than the physical ability to withstand bariatric surgery is the patient's psychological capacity to learn, comply, and adapt to the changes that will occur during the perioperative cycle. Social support systems should be identified during the psychological evaluation as the best outcomes involve the presence of family members, friends, and a community that supports the patient's weight-loss journey with bariatric surgery. This evaluation will also identify barriers to postoperative success through a lack of social or emotional support in these areas (Lim, 2022a; Schlottman et al., 2018; Stahl, 2022).
A registered dietician (RD) should complete a nutritional evaluation. This assessment will focus on preoperative weight loss efforts, a nutritional assessment of current eating behaviors, and education on postoperative eating behaviors that must be strictly followed. Although some controversy exists over the need for preoperative weight loss for long-term success, studies show that preoperative nutritional counseling is vital to the success of postoperative dietary compliance. A careful evaluation of micronutrient and macronutrient measurements should be completed during the nutritional assessment. A nutritionist or RD should educate the patient on the postoperative diet components before all bariatric surgical procedures. However, for patients undergoing a malabsorptive bariatric procedure such as the gastric bypass or the biliopancreatic diversion with duodenal switch, a more extensive perioperative nutritional evaluation should be done to offset anticipated deficiencies, as the portion of the intestines is removed that allows for the most efficient absorption of vitamins and minerals. These patients may have a deficiency of iron, calcium, magnesium, and vitamins, including B12 (Dagan et al., 2017; Lim, 2022a; Schlottman et al., 2018; Stahl, 2022).
Preoperative gastrointestinal (GI) imaging or an upper GI radiographic series should be completed to pinpoint any pre-existing anatomical or physiological abnormalities. As the GI tract will be modified during bariatric surgery, this provides a preoperative view of the esophagus and gastric anatomy, including esophageal clearance and the presence or size of a hiatal hernia. In addition, an abdominal ultrasound is recommended to assess for biliary tract pathology. If undiagnosed cholelithiasis is present, the rapid weight loss induced by bariatric surgery can provoke existing gallstones to become symptomatic. The ultrasound should also assess for steatosis (abnormal retention of fats), fibrosis (abnormal amounts of scar tissue), or the presence of nonalcoholic steatohepatitis (inflammation with concurrent fat accumulation) of the liver. Esophagogastroduodenoscopy (EGD) should be done in the preoperative evaluation of a bariatric surgical candidate. The pharynx, esophagus, stomach, and duodenum are evaluated using a flexible endoscope. This procedure can rule out any underlying GI disease, severe esophagitis, Barrett's esophagus, or malignancy of the upper GI tract (Lim, 2022a; Schlottman et al., 2018; Stahl, 2022).
While there is controversy over preoperative weight loss requirements, some studies show that patients with a preoperative weight loss requirement have a higher percentage of excess weight loss (EWL) at 6 months post-surgery. The healthcare team will determine the individual goals of each bariatric patient before surgery. One advantage of preoperative weight loss is that abdominal fat and liver volume are reduced and can improve access to the stomach during laparoscopic procedures, shortening the operative time (Lim, 2022a; Schlottman et al., 2018; Stahl, 2022).
The major contraindications to bariatric surgery are psychological features that might amplify the impact of the surgery or physical conditions or comorbidities that put a patient at extremely high risk for complications, such as cardiac or other conditions. However, most patients benefit from the procedure and subsequent weight loss, making their clearance for surgery likely (Lim, 2022a; Schlottman et al., 2018; Stahl, 2022). See Table 1 for the preoperative checklist recommended for all bariatric surgery procedures in the 2019 updated clinical practice guidelines.
Preoperative Checklist for Bariatric Surgery
(Mechanick et al., 2020)
Perioperative Care for Bariatric Patients
Preoperative Nursing Care
Nurses should discuss postsurgical weight loss goals. Each patient and their healthcare team should develop goals based on the patient's situation and willingness to comply with future restrictions (ASBMS, 2021; Schlottman et al., 2018). Nurses should focus on the following during preoperative care:
- Patient care needs:
- identify individual physical risk factors and develop a plan to offset any anticipated risk
- develop relationships with the healthcare team to improve adherence post-surgery
- discuss the strengths and weaknesses of the patient and their support system (ASBMS, 2021; Lim, 2021)
- Education topics:
- the specific procedure to be performed and the associated risks
- discharge planning for surgery
- the importance of dietary compliance and follow-up with HCPs
- what and how much food can be eaten after surgery
- understanding the connection between food and triggers to overeating and behavioral changes that can lead to a healthier lifestyle
- the importance of exercise to prepare mentally and physically for surgery and continuation after surgery (ASBMS, 2021; Lim, 2021)
Postoperative Nursing Care
Patient care needs focus on maintaining respiratory and cardiac functioning, pain management, and early recognition of surgical complications during the surgery and in the postoperative period. In the early postoperative cycle, nurses should focus on each patient's pain, safety, and hydration. Patient care needs should include the following:
- maintenance of airway/breathing through the use of incentive spirometry or other respiratory therapies
- continuous monitoring of vital signs
- administration of IV fluids and any other ordered medications
- regular monitoring for bleeding
- pain management
- venous thromboembolism event (VTE) prophylaxis (ASBMS, 2021; Lim, 2021)
See Table 2 for early postoperative care outlined in the 2019 updated clinical practice guidelines.
Early Postoperative Care
Roux-En-Y Gastric Bypass
Monitored telemetry for 24 hours if high risk for MI
Protocol-derived staged meal progression supervised by RD
Healthy eating education by RD
Calcium citrate 1200-1500 mg/day
Multivitamin plus minerals (tabs for minimum requirement)
Vitamin D, at least 3000 units/day, titrate to >30 ng/mL
Vitamin B12 as needed for normal range
Adequate hydration (>1.5 L/d PO)
Blood glucose monitoring with diabetes or hypoglycemic symptoms
Pulmonary hygiene, spirometry, DVT prophylaxis including TED hose and sequential circulatory devices (SCDs)
If unstable consider pulmonary embolus (PE), intestinal leak
If rhabdomyolysis (breakdown of damaged skeletal muscle) is suspected, check CPK
(Mechanick et al., 2020)
Nurses should provide postoperative patient education on:
- reporting pain to the nurse before it becomes severe and taking pain medication routinely and as needed during the immediate postoperative period
- early ambulation to decrease complications and asking for assistance before getting out of bed to avoid injury
- using an incentive spirometer and other respiratory treatments to avoid postoperative pneumonia
- maintaining nothing by mouth initially, followed by a gradual dietary introduction of liquids, progressing to a pureed diet
- the postoperative medication regime (Hamad, 2021; Mechanick et al., 2020; Seelbach & D'Almeida, 2021)
Nurses should provide dietary education for bariatric surgery patients in the early days after surgery. Important education points should consist of the following (Hamad, 2021; Kushner et al., 2022; Mechanick et al., 2020; Seelbach & D'Almeida, 2021):
- Start with a clear liquid diet before progressing to thicker liquids.
- After 2 weeks, start a blended, pureed diet. Liquid supplements or powders can meet the protein requirements during this period.
- Eat small meals every 2 hours.
- Foods should be high in protein and low in carbohydrates, calories, fat, and sugar.
- Fluids should be consumed between meals, with a goal of 1 cup of fluids between each small meal, 6 to 8 times per day, for a total of 64 ounces of fluids daily.
- Maintain a log of all food consumed and protein intake, with a protein goal of 65 to 75 grams daily post-surgery (this may take some time to achieve).
- Chew food thoroughly and take small bites.
- Do not use straws or chew ice, as this introduces air into the stomach and causes pain.
- Caloric intake for the first 2 months should remain around 300 to 600 calories per day, focusing on thin and thicker liquids, not exceeding 1000 calories.
- Avoid rice, bread, raw vegetables, fresh fruits, and carbonated or sugary beverages.
- Avoid pork or steak that is hard to chew; ground meats can be eaten.
- Avoid alcohol, as this is absorbed more rapidly and can cause an increased effect on blood alcohol levels.
- Liquid vitamin supplements are best. Others should be crushed or cut into small pieces.
- A multivitamin with selenium, copper, zinc, 400 mcg of folic acid, and 18 mg of iron is advised. Take two tablets daily for at least 3 months after surgery, followed by one tablet daily for life.
- Take a calcium supplement with 1200 to 2000 mg daily.
- Take a vitamin D supplement with 800 to 1000 IU daily.
- Take an oral or sublingual vitamin B complex supplement with 500 mcg daily.
Complications of Bariatric Surgery
Since most bariatric procedures are performed laparoscopically, the surgical risk is lower than with traditional open abdominal surgeries, including wound infections and delayed healing. However, the risk involved with general anesthesia and rerouting of the GI tract is unchanged. The most common postsurgical risks include VTE, bleeding, and bowel obstruction. Anesthesia risks are a concern with any surgery, but this risk increases for patients with severe obesity. However, improved anesthesia and surgical management have decreased this risk, and appropriate cardiac and pulmonary function testing during the preoperative evaluation for bariatric surgery can still reduce it (Albaugh & Abumrad, 2018).
The risk for blood clots or VTE is a primary concern postoperatively for patients with morbid obesity. Early ambulation after surgery is the most effective method for preventing VTE. Mechanical and pharmacological prophylaxis should also be ordered, including lower extremity compression stockings, sequential circulatory devices (SCDs), and pharmacologic prophylaxis. The use of low molecular weight heparin is suggested for bariatric patients, such as enoxaparin (Lovenox), parnaparin (Baflux), or dalteparin (Fragmin), over unfractionated heparin (Heparin sodium). Evidence has shown a decrease in VTE with the use of low-molecular-weight heparin and no increased postoperative bleeding rates among this group. However, bleeding precautions should be implemented, and nurses should monitor for bruising or bleeding and avoid invasive procedures. Bleeding related to the surgery is possible but rare. Most facilities perform a postoperative upper GI series to rule out bleeding or leakage in gastric bypass, sleeve gastrectomy, and biliopancreatic diversion with duodenal switch patients. Symptoms indicating bleeding could include hematemesis, severe left upper quadrant pain, back and shoulder pain, intractable hiccups, severe nausea with retching, and melena. For a suspected bleed, nurses should contact a provider immediately (Hamad, 2021; Lim, 2021; Seelbach & D'Almeida, 2021).
Bowel obstruction is an unlikely but potentially serious complication of bariatric surgery. This complication is often associated with the gastric bypass procedure but can occur with other procedures. The obstruction can be related to adhesions, internal hernia, intussusception (when one section of the intestine telescopes inside another and causes a blockage), and intraluminal clots or strictures. In addition, there may be defects of the mesentery bowel that lead to an obstruction. These patients typically complain of severe abdominal pain, nausea, and vomiting. The abdomen will typically be tender to palpation but without rebound tenderness. A patient with intussusception may present with currant jelly stools, an abdominal mass, or peritonitis. Regardless of the cause, surgical intervention is typically required to correct this condition (Clapp, 2015; Hamad, 2021; Lim, 2021; Seelbach & D'Almeida, 2021).
Bariatric Surgery Short- and Long-Term Effects
The most significant impact of bariatric surgery, both long- and short-term, is weight loss. Weight loss can lead to increased activity, improved overall health, and greater self-esteem. More than 90% of individuals who undergo weight loss surgery maintain 50% of their EWL after surgery, and more than 80% maintain over 50% of their EWL after surgery, indicating long-term success with these procedures. Population-based studies involving obese individuals have demonstrated that those undergoing bariatric surgery have a lower risk of mortality than their counterparts who do not have surgery. One study showed an 89% reduction in mortality over 5 years for patients who elect to proceed with bariatric surgery versus those who do not (ASBMS, 2021). In addition, improvement in the following co-existing diseases has been found across studies:
- type 2 diabetes
- gastroesophageal reflux disease
- fatty liver disease
- urinary stress incontinence
- venous stasis
- hyperlipidemia (ABSMS, n.d., 2021)
Most patients report improved sleep, ability to complete activities of daily living, and overall improved quality of life after surgery. Depression, anxiety, and other mental health illnesses often improve as well. Sexual function, relationships, and social interactions frequently improve, and patients often report improved employability (ASBMS, n.d., 2021).
Bariatric Surgery in Adolescents and Children
Children and adolescents are also affected by obesity. Up to 80% of children with obesity will be affected by obesity in adulthood. They are often affected by the same weight-related conditions as adults, including hypertension, OSA, type 2 diabetes, and asthma. Additionally, children and adolescents are often bullied or victims of weight bias, inducing depression and anxiety. While non-invasive treatments such as lifestyle modification, pharmacotherapy, and behavioral therapy are preferred, some cases require more drastic measures, including bariatric surgery. The most common procedures in children and adolescents are gastric bypass, adjustable gastric band, and sleeve gastrectomy. The goal of bariatric surgery in this population is to provide the most significant benefit with the lowest risk (ASMBS, 2022; Inge, 2021; Skelton & Klish, 2022). Criteria for this age group are:
- BMI 35 or higher with major comorbidities (type 2 diabetes, moderate to severe OSA, pseudotumor cerebri, or fatty liver disease)
- BMI 40 or greater with less severe comorbidities (hypertension, hyperlipidemia, mild or moderate OSA; ASMBS, 2022; Inge, 2021; Skelton & Klish, 2022)
There appear to be short-term benefits to bariatric surgery in this population, with improved depression, quality of life, and fewer eating disturbances. Negative psychosocial risks could exist but are not well documented. Vitamin and nutritional deficiencies may exist, both short- and long-term, and must be monitored closely to ensure proper growth and development during adolescence. Informed consent among children occurs as part of a formal agreement called "assent." Assent involves each child in the decision-making process and seeks to ensure they agree with the surgery without coercion from their family or medical staff. The clinical team must carefully consider an adolescent's ability to make decisions cognitively, socially, and emotionally. It is optimal to have a supportive family and a willing, committed child on the same page regarding their future health decisions. In situations where this does not exist, the HCP must ensure that all efforts are made to ensure the child's best interests are considered by all parties involved (ASMBS, 2022; Inge, 2021).
Future Opportunities in Bariatrics
While already in practice with some healthcare organizations, the intragastric balloon is a more recent weight-loss procedure that does not require surgery. The procedure is an option for those who are overweight/obese when diet and exercise have not been successful. Like bariatric surgeries, a commitment to lose weight must be considered for the intragastric balloon. Patients must make permanent healthy choices in their diet with an exercise routine to have long-term success with the procedure (Crossan & Sheer, 2022a). This procedure is an option for individuals who have the following:
- a BMI between 30 and 40
- a willingness to commit to a healthy lifestyle and follow the medical plan, including behavioral therapy
- no previous esophageal or stomach surgeries (Crossan & Sheer, 2022a)
An intragastric balloon can be placed in an outpatient procedure in an endoscopy suite using sedatives and avoiding general anesthesia. This balloon makes patients feel full faster, decreasing the amount of digested food. The balloon also appears to change the hormones that control appetite, improving satiety. The amount of weight loss depends on the corresponding changes in lifestyle habits. The typical weight loss is 7% to 15% of body weight in the first 6 months after placement. For those receiving concurrent behavioral therapy, the average weight loss increases to 29% of their EBW, compared to only 14% of EBW among the group that received behavioral therapy alone. Minor complications for the intragastric balloon include pain and nausea after the insertion that subsides within hours to days and can be treated with oral medications. A serious risk includes balloon deflation, allowing it to move through the digestive system, causing a blockage, and requiring surgery to retrieve it. Other possible risks include ulcerations or perforations in the stomach that could require surgical repair (Crossan & Sheer, 2022a).
Another non-surgical weight loss device approved by the US Food and Drug Administration (FDA) is the Electrical Stimulation System (Maestro Rechargeable System), which blocks nerve activity between the brain and the stomach. The FDA notes that the system is no longer marketed as of September 2018 but is still in use. The Gastric Emptying System (AspireAssist) is a third option approved by the FDA. This device is a tube inserted between the stomach and outside of the abdomen with a port to drain food after eating. The Oral Removable Palatal Space Occupying Device (Sensor Monitored Alimentary Restriction Therapy [SMART] Device) is worn during meals to limit the bite size. The Ingested, Transient, Space Occupying Device (Plenity) is an ingested material that briefly occupies space in the stomach (FDA, 2020).
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