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Taking the weight off with bariatric surgery

GALLAGHER, SUSAN RN, MSN, PHD

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As more patients choose weight-reduction surgery to treat morbid obesity, you're likely to be involved in their care. Here's the skinny on the various options and your role before and after surgery.

Al Roker, move over. Here's the skinny on an increasingly popular surgical treatment for obesity.

Susan Gallagher is clinical affairs coordinator for SIZEWise Rentals of Ellis, Kan.

The author has disclosed that she is employed by SIZEWise Rentals, which makes beds and other equipment for obese patients.

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AN ESTIMATED 6% to 10% of American adults are morbidly obese, defined as a body mass index (BMI) greater than 40 kg/m2. Excess weight increases a person's risk of a host of diseases and disorders, from hypertension and heart disease to degenerative joint disease. (For more on the health risks of obesity, see Reaping the Benefits of Downsizing.) For some of these patients, bariatric surgery can literally be a lifesaver.

Bariatric surgery, which involves surgically reducing stomach capacity, is indicated for dangerously obese patients who haven't been able to reduce weight with medically supervised diets, exercise, and behavior modification. An estimated 100,000 people had bariatric surgery in 2003, and that number is expected to grow.

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Beyond calories

Obesity is a complex disorder with many contributing metabolic, psychological, and genetic factors. The traditional view that obese people gain weight because they eat more and exercise less than people of normal weight is only part of the picture. People have remarkably varied energy requirements; some of us can eat twice as much as others and never gain weight.

Recent research indicates that ghrelin, a hormone produced by endocrine cells in the stomach, triggers hunger and that controlling ghrelin may be a key to managing weight.

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The evolution of weight-loss surgery

Bariatric surgery—which derives its name from the Greek words for “weight” and “treatment”—was introduced in the 1950s. An early form of bariatric surgery involved removing part of the small intestine from the nutrient absorptive circuit. Because of numerous complications and deaths, this technique is no longer common.

Today, most bariatric surgeries fall into one of two broad categories: gastric restrictive surgery and combined gastric restriction and malabsorption surgery. (See Stapling, Banding, and More: Options in Bariatric Surgery for details.)

Although many bariatric sur-geries can be done laparoscopically, bariatric surgery is still major abdominal surgery, with all its risks. To justify the risks and enjoy long-term benefits from surgery, a patient must be willing and able to modify her postoperative eating behavior and take nutritional supplements to keep the weight off and avoid nutritional deficiencies.

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Who's eligible for surgery?

Bariatric surgery is indicated for morbidly obese patients who are motivated, who understand the risks and benefits of surgery, and for whom the benefits of surgery are greater than the risks. Although bariatric surgery is usually reserved for patients considered morbidly obese, some patients with BMIs between 35 and 40 kg/m2 may be candidates if they have concurrent high-risk conditions, such as obstructive sleep apnea or poorly controlled hypertension or diabetes.

Bariatric surgery isn't appropriate for patients who can't cooperate with the postoperative program.

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Preoperative nursing care

To minimize surgical risks, a patient's blood pressure (BP) and pulmonary function should be optimized before surgery and any preoperative abnormalities in lab values corrected. If the patient smokes, encourage her to stop. If the patient is a woman of childbearing potential, tell her to use reliable birth control to avoid becoming pregnant before surgery and in the first postoperative year.

A bariatric nurse coordinator can help plan an interdisciplinary approach to meeting the patient's emotional and physical needs. For example, the team should be sure to have larger gowns available in the operating room to prevent embarrassing the patient with a gown that doesn't cover her properly.

Before surgery, assess your patient's understanding of the lifelong commitment involved in bariatric surgery. Education will help her regain her health and enjoy a better quality of life after surgery.

Teach her deep breathing, coughing, and leg exercises ahead of time. After surgery, when her respirations may be shallow because of incisional pain, analgesia, immobility, and obesity itself, respiratory techniques help prevent atelectasis. Show her how to splint her incision and use an incentive spirometer.

Wearing an abdominal binder at least 2 inches (5 cm) below the xiphoid process also encourages deep breathing. Make sure the binder fits properly. She should be able to slip at least one finger beneath the binder easily. Remove it every 4 hours so you can assess the skin for irritation.

Leg exercises help maintain proper circulation postoperatively and reduce the patient's high risk of deep vein thrombosis (DVT) and pulmonary embolism. (Pneumatic compression devices usually are applied in the operating room and used throughout the acute care stay.)

If she'll have a patient-controlled analgesia (PCA) pump for postoperative pain management, teach her how to use it.

Alert postanesthesia care unit nurses that they'll be receiving an obese patient so they can have the correct size equipment available. Standard-sized equipment such as BP cuffs may be too small for a patient who's obese.

During surgery, an additional nurse may be added to the surgical team to help position the patient. She can also help hold heavy skin folds apart as the surgical team disinfects and prepares the surgical site.

Extra personnel also may be needed after surgery, to help place the patient on a stretcher or oversized bed for transfer to the hospital room. Specialized bariatric equipment, such as a lift-and-transfer system, heavy-duty slide board, or hover-type product, may be available to help with transfers.

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Postoperative monitoring

During the recovery period, routinely monitor the patient's vital signs, assess for complications, and provide skin and wound care. Reposition the patient, tubes, and catheters every 2 hours.

She'll probably have a PCA pump for pain management. Assess and document her pain level regularly using a standard numeric pain scale and make sure her pain is under control.

Encourage the patient to perform the respiratory and leg exercises you taught her before surgery. Position the head of the bed at least 30 degrees (semi-Fowler's position) to help breathing by reducing the weight of abdominal adipose tissue pressing on the diaphragm.

To reduce the risk of immobility-related complications, encourage early ambulation. If your patient was a good candidate for bariatric surgery, she was probably relatively healthy before the operation. Unless pain and sedation interfere, she may be able to turn herself, walk, and transfer to a chair within 8 hours after surgery. The only special accommodations she may need are a bed wide enough for her to turn on, a walker to support her weight for the first few postoperative days, and an overhead trapeze to help her reposition herself.

If your patient doesn't resume activity quickly, modify your plan of care to prevent or address complications related to immobility. Because of her size and obesity, she's prone to atypical pressure ulcers. For example, pressure from side rails and armrests on equipment not designed to accommodate an unusually large person can cause pressure ulcers on the hips.

Pressure within skin folds also can cause skin breakdown, and tubes and catheters can burrow into skin folds, eroding the tissue. Using equipment properly sized for the patient can minimize her risk of skin breakdown.

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Stay alert for surgical complications

Suspect an anastomotic leak, abdominal compartment syndrome, internal bleeding, or sepsis if the patient's abdomen becomes rigid, hemoglobin and hematocrit fall, potassium rises, and the patient complains of nonincisional abdominal pain, or if her lab results indicate metabolic acidosis. Fever, tachycardia, and dehydration may point to sepsis related to a gastrointestinal leak. Notify the surgeon immediately if any of these changes occur.

An obese patient is also at added risk for wound dehiscence and slow wound healing because of insufficient blood supply to fatty tissue or a diet lacking essential vi-tamins and nutrients. A wound may heal slowly if it's within a skin fold, where excess moisture and bacteria can accumulate. Excess body fat also puts more strain on wound edges. An abdominal binder can help support the area and reduce the risk of wound dehiscence.

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Special pulmonary considerations

Many morbidly obese patients have one of these preexisting pulmonary problems:

  • obesity hypoventilation syndrome. The weight of fatty tissue on the rib cage prevents the chest wall from expanding fully, resulting in ventilatory insufficiency.
  • obstructive sleep apnea. The weight of excess fatty tissue in the neck causes the throat to narrow, severely restricting or obstructing breathing for seconds or minutes. Putting the patient in semi-Fowler's position or using continuous positive airway pressure ventilation at night can help improve breathing.

If the patient needs long-term ventilatory support, she may need a particularly large tracheotomy to locate the trachea. This larger wound can be complicated by bleeding, infection, or damage to surrounding tissues. Standard-sized tracheostomy tubes may be inadequate, and narrow cloth tracheostomy ties can burrow into skin folds of the neck, further damaging skin. Use wider, longer ties and provide meticulous postoperative tracheostomy care.

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Eating again

After bowel sounds return and the patient can eat, provide six small feedings totaling 600 to 800 calories a day and encourage fluid intake to prevent dehydration. The patient's diet will advance from clear liquids to a regular diet.

If her recovery progresses smoothly, she'll be discharged after about 5 days with detailed dietary instructions. The patient's diet should contain foods high in protein, and she should avoid sweetened beverages, alcohol, and foods high in sugar and fat. Medications should be provided in liquid form. She'll also be taught to recognize signs and symptoms of infection, dehydration, and DVT and learn when to notify her health care provider.

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Physical and emotional adjustments

Life after bariatric surgery often brings enormous emotional challenges as the patient adjusts to her rapidly changing body. As the weight drops off, she may panic and feel vulnerable, weak, or empty. She may also become confused, anxious, or depressed when she discovers that being thin doesn't fix other problems in her life. She may even regret having had the surgery.

Some patients experience a “hibernation phase” during the first 3 to 4 weeks after surgery and may feel fatigued as the body adjusts to what it perceives as starvation. Emotional adjustment can be overwhelming, and support groups can be valuable at this time. Exercise also is important during this transition, to increase metabolism and energy levels and to promote well-being and self-confidence.

The patient may have unrealistic expectations of what her thinner body will look like and may have a significant problem with hanging skin. This can be addressed with plastic surgery (such as panniculectomy, to remove excess abdominal skin folds) after her weight has stabilized, usually in about a year.

Body image disturbance, in which people incorrectly estimate their size, is common after bariatric surgery. No matter how much weight the patient loses, she still may feel fat.

Encourage your patient to deal with any distressing psychological issues. Doing so will help her succeed in reaching her weight goal and increase the likelihood that she can continue to manage her weight.

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Gastric bypass complications

If your patient had gastric restricttion and malabsorption surgery, which bypasses the stomach and duodenum, she's at risk for such late complications as anemia and calcium and vitamin B12 deficiency. She'll need lifelong nutritional supplementation to prevent these problems.

Dumping syndrome, another possible complication of gastric bypass, occurs when the patient eats refined sugar. She may experience tachycardia, nausea, tremor, dizziness, abdominal cramps, fatigue, and diarrhea. Teach her to avoid foods high in sugar and fat.

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In the long run

Although the long-term benefits and risks of bariatric surgery aren't fully known, it helps many patients reduce or eliminate some obesity-related health conditions. By understanding your role before and after surgery, you can help your patient achieve her goal for better physical and psychological health.

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Reaping the benefits of downsizing

When an obese patient loses a significant amount of weight, she lowers her risk of these obesity-related complications:

  • hypertension (obesity doubles a patient's risk)
  • hypertrophic cardiomyopathy
  • hyperlipidemia
  • diabetes
  • cardiovascular disease (70% of cardiovascular disease is related to obesity)
  • gallbladder disease
  • obstructive sleep apnea
  • obesity hypoventilation syndrome
  • degenerative arthritis
  • breast and colon cancer
  • psychosocial problems
  • early death.
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Stapling, banding, and more: Options in bariatric surgery

Gastric restriction surgeries use surgical staples or circumgastric banding to reduce the size of the stomach to 15 ml. This type of surgery is purely restrictive, so food is digested normally and the risk of anemia or vitamin B12 deficiency is low.

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SELECTED WEB SITES

Obesity Help

http://www.obesityhelp.com

American Society for Bariatric Surgery

http://www.asbs.org

Obesity-Surgery.Net

http://www.obesity-surgery.net/obesity_surgery_faq.htm

Last accessed on February 3, 2004.

To take this test online, visit http://www.nursingcenter.com/ce/nursing.

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SELECTED REFERENCES

French, G., et al.: “The Nurse's Role in Bariatric Surgery,” in Update: Surgery for the Morbidly Obese Patient, M. Deitel and G. Cowan (eds). North York, Canada, FD Communications, 2000.
    Gallagher, S.: “Bariatrics: Considering Mobility, Patient Safety, and Caregiver Injury,” in Back Injury among Health Care Workers—Causes, Solutions, and Impacts, W. Charney and A. Hudson (eds). New York, N.Y., Lewis Publishers, CRC Press, 2003.
      Garza, S.: “Bariatric Weight Loss Surgery: Patient Education, Preparation, and Follow-Up,” Critical Care Nursing Quarterly. 26(2):101–104, April-June 2003.
      Owens, T.: “Morbid Obesity: The Disease and Comorbidities,” Critical Care Nursing Quarterly. 26(2):162–165, April-June 2003.
      Woodward, B.: “Bariatric Surgery Options,” Critical Care Nursing Quarterly. 26(2):89–100, April-June 2003.
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      Source

      National Institute of Diabetes and Digestive and Kidney Diseases.
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        Taking the weight off with bariatric surgery

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        Taking the weight off with bariatric surgery

        GENERAL PURPOSE To provide nurses with an overview of bariatric surgery as a treatment option for morbid obesity. LEARNING OBJECTIVES After reading the preceding article and taking this test, you should be able to:

        1. Identify the effect of obesity on health care.
        2. List four surgical options in bariatric surgery.
        3. Outline preoperative and postoperative management strategies for patients undergoing bariatric surgery.

        1. About what percentage of American adults is morbidly obese?

        a. 1% to 5%

        b. 6% to 10%

        c. 11% to 15%

        d. 16% to 20%

        2. Recent research identifies which hormone as a trigger for hunger?

        a. growth hormone

        b. thyroid-stimulating hormone

        c. ghrelin

        d. erythropoietin

        3. Which statement is correct about bariatric surgery?

        a. About 10,000 people had bariatric surgery in 2003.

        b. Bariatric surgery was introduced in the 1970s.

        c. An early form of bariatric surgery involved removing part of the esophagus from the nutrient absorptive circuit.

        d. Bariatric surgery derives its name from the Greek words for “weight” and “treatment.”

        4. Some patients with BMIs between 35 and 40 kg/m2 may be candidates for bariatric surgery if they

        a. are pregnant.

        b. have poorly controlled hypertension.

        c. can't cooperate with the postoperative program.

        d. understand that the risks of surgery are greater than the benefits.

        5. Which statement is correct about using an abdominal binder?

        a. It encourages deep breathing.

        b. It should be worn at least 2 cm below the xiphoid process.

        c. It should be tight enough to prevent even one finger from slipping beneath it.

        d. It should be removed at least once every 8 hours for skin assessment.

        6. Postoperative bariatric surgery care includes

        a. repositioning the patient's tubes and catheters every shift.

        b. keeping the head of the bed flat.

        c. using properly sized equipment.

        d. repositioning the patient every 4 hours.

        7. Which sign or symptom suggests a possible anastomotic leak?

        a. metabolic alkalosis

        b. incisional abdominal pain

        c. hypokalemia

        d. a rigid abdomen

        8. An insufficient blood supply to fatty tissue increases the postoperative risk of

        a. atelectasis.

        b. DVT.

        c. wound dehiscence.

        d. pulmonary embolism.

        9. Ventilatory insufficiency caused by the weight of fatty tissue preventing full chest-wall expansion best describes

        a. obesity hypoventilation syndrome.

        b. pulmonary embolism.

        c. pneumonia.

        d. obstructive sleep apnea.

        10. When bowel sounds return and your patient can eat, give her six small feedings totaling how many calories per day?

        a. 400–600

        b. 600–800

        c. 800–1,000

        d. 1,000–1,200

        11. Discharge dietary instructions should encourage the patient to eat foods that are

        a. high in fat.

        b. low in amino acids.

        c. high in protein.

        d. high in sugar.

        12. The feeling of fatigue during the first 3 to 4 weeks after surgery as the patient's body adjusts to perceived starvation is called the

        a. plateau phase.

        b. honeymoon phase.

        c. repolarization phase.

        d. hibernation phase.

        13. Plastic surgery to remove excess abdominal skin folds is called

        a. papillectomy.

        b. pallidectomy.

        c. patellectomy.

        d. panniculectomy.

        14. Late complications associated with gastric restriction and malabsorption surgery include

        a. polycythemia.

        b. vitamin B12 deficiency.

        c. hypercalcemia.

        d. hypophosphatemia.

        15. Tachycardia, abdominal cramps, and diarrhea after eating refined sugar following gastric bypass may indicate

        a. Horner's syndrome.

        b. Marfan syndrome.

        c. dumping syndrome.

        d. Stokes-Adams syndrome.

        16. Obesity doubles a patient's risk of

        a. diabetes.

        b. hypertension.

        c. hyperlipidemia.

        d. hypertrophic cardiomyopathy.

        17. What percentage of cardiovascular disease is related to obesity?

        a. 40%

        b. 50%

        c. 60%

        d. 70%

        18. Gastric restriction surgeries reduce the size of the stomach to

        a. 15 ml.

        b. 30 ml.

        c. 45 ml.

        d. 60 ml.

        19. Which statement best describes circumgastric banding?

        a. Surgical staples are used to reduce stomach capacity.

        b. A polypropylene band is placed at the lower end of a pouch.

        c. An inflatable band is placed around the fundus of the stomach.

        d. A small stomach pouch is created with an anastomosis to the jejunum.

        20. Which of the following is also known as Roux-en-Y gastric bypass?

        a. gastric resection

        b. vertical banded gastroplasty

        c. circumgastric banding

        d. gastric restriction and malabsorption surgery

        Table

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