Sleeve gastrectomy is a new procedure that helps promote early satiety and thus limits consumption without the radical reconstruction of Roux-en-Y surgery. Sleeve gastrectomy also helps to lower ghrelin levels, minimizes dumping syndrome, and lowers malnutrition risks through a reduction in malabsorption. Unfortunately, insufficient evidence demonstrating long-term success rates and potential complications is available to encourage third-party payers to cover the cost of the procedure willingly; however, more insurance providers are recognizing and adding the procedure to the list of acceptable bariatric interventions. Complications include gastric leak, nausea, stricture development, and reflux.
Adjustable gastric banding (AGB), a less radical method of restricting oral intake without a malabsorption component, was developed in the 1980s. The first AGB placement occurred in the United States as an open abdominal surgical procedure in 1986. It was converted to the popular laparoscopic procedure in 1993. While AGB successfully limits oral intake, its effectiveness is primarily rooted in the patient controlling the frequency and quality of foods consumed.
AGB is reversible and generates slower weight loss than other types of bariatric surgery. An inflatable silicone band placed around the upper aspect of the stomach can be inflated or decompressed with saline via a port secured to abdominal muscle. The exact amount of inflation is determined by the patient and his or her bariatric specialist based on the patient’s degree of hunger and satiety, exercise, dietary intake, and tolerance. Band adjustments are not made for the purpose of achieving a specific rate of weight loss. Most facilities inflate the band every four to 12 weeks until an optimal restriction is achieved in which the patient experiences appropriate satiety with adequate dietary intake of healthy solid foods to achieve a weekly weight loss of 1 to 2 lbs.
The rate of weight loss will diminish after the initial six to 12 months; however, increasing the degree of restriction is not appropriate when the patient is unable to tolerate solid foods that contain protein. With gastric banding and optimal restriction, the patient will continue to tolerate oral consumption of most solid foods with the exception of thick breads and dense meats. AGB patients also need to restructure their frequency of dietary intake and their technique for consuming solid and liquid foods, and to recapture the satiety signal the stomach sends to the brain. Healthy food choices with a significant portion of protein components help promote optimal and efficient dietary intake in small caloric quantities. Patients learn to take small bites and chew thoroughly to enable food to progress through the band into the stomach cavity for normal gastric processing. Liquids are limited to include only such low-calorie fluids as water, sugar-free noncarbonated drinks, and tea. Such high-calorie drinks as smoothies and lattés are not appropriate.
Complications of AGB include band over-restriction, band slippage, erosion, esophageal or pouch dilation, band failure, infection, obstruction, and need for reoperation. The band system may be removed the same way it is placed; however, weight regain is certain to occur when the restriction provided by the band is no longer present.
Vomiting or abdominal pain are never normal after the initial postoperative recovery. Vomiting suggests dehydration, development of a stricture, or other complications in the bypass patient, or an over-restricted band within the AGB patient. Abdominal pain may reflect a leak, infection, or erosion. When a bariatric patient presents with symptoms of nausea, vomiting, or abdominal pain of unclear etiology, include potential bariatric surgery complications in the list of differential diagnoses. If an abdominal evaluation and assessment is benign, refer the patient back to his or her bariatric specialist.
A recent study comparing the gastric Roux-en-Y surgery with AGB resulted in significant findings.31 Patients with a BMI >50 experienced better weight loss with the gastric Roux-en-Y. For unclear reasons, the male gender was a predictive factor for weight-loss failure related to AGB. In general, the bypass surgery came with a higher 30-day complication rate and one-year mortality rate compared with AGB, but with a higher four-year percentage of excess weight loss. Quality-of-life scores improved equally at the one-year mark for both procedures. This study validates the belief that the best surgical procedure for weight loss is not a choice based solely on personal preference but requires in-depth individualized evaluation of the etiology of the patient’s obesity. Additionally, certain medical histories hinder and possibly exclude the option of pursuing bariatric surgery, including surgically corrected reflux, end-stage renal disease, cancer, advanced or untreated liver disease, ongoing alcoholism or drug addictions, and uncontrolled mental illness.
Implications for practice
Primary-care providers play a vital role in containing the obesity epidemic. Encouraging healthy behaviors early in life advances goals for healthy living. But once a person has become obese, weight loss becomes an important aspect of his or her health plan. Prescribing a weight-loss regimen that includes a possible referral for bariatric surgery should occur after the patient has tried and failed to make dietary changes and to exercise, and before the patient is no longer able to participate in an exercise program. Perhaps the biggest misconception associated with bariatric surgery is that it is an easy way to lose weight. Those who have successfully undergone the operation and have achieved their goal weight will admit it still requires healthful eating and routine exercise. Health-care providers have a responsibility to guide patients on their weight loss-endeavors and to help recognize when a person might need assistance from prescription weight-loss medications or a referral for bariatric surgery. Table 3 identifies specific criteria to consider before making a referral to bariatric surgery.
Many third-party payers require documentation of medically supervised weight-loss programs ranging three to 12 months in length. The documentation should include the candidate’s height, weight, BMI, dietary and exercise plans, and a psychosocial evaluation. The documentation may be very detailed or as simple as indicating that the patient is attending an exercise gym and following a specific dietary plan. Evaluation of the person’s degree of commitment to making lifestyle changes helps to determine the areas in which he or she needs further guidance and support while establishing realistic, concrete goals.
When patients seek advice on weight loss, begin with an overall evaluation of their health. Is there any cardiac or pulmonary disease that needs stabilization or special monitoring during the development of an exercise program? Does the person suffer from anemia, vitamin deficiency, or another occult issue that manifests as activity intolerance? Also, be sure to to evaluate the psychosocial issues: Look for eating disorders, emotional eating, addictive behaviors, manic-depressive tendencies, exposure to abuse, and work schedules. Does the person have the proper emotional and financial support to make lifelong changes in behavior?
Many obese individuals are able to lose weight successfully with encouragement. However, when the weight-loss plan is failing to achieve the desired outcomes, re-evaluate for undiagnosed comorbidities, including hypothyroidism, sleep apnea, and diabetes mellitus. If referral to a bariatric surgery program becomes necessary, strongly consider and recommend a Centers of Excellence program that offers not only the surgery but also comprehensive nutrition, physical therapy, and psychological support systems. These support systems should be in place and available for at least the first year postoperatively to encourage and reinforce the identified behavior changes required to ensure long-term success.
As with other unhealthy behaviors, poor diet contributes to devastating health consequences; unfortunately, obesity and food overindulgence are not always viewed as a steppingstone to chronic diseases. A study in the United Kingdom revealed that although hospitalized patients were frequently screened for alcohol and tobacco use, few were asked about their dietary and exercise habits or their weight-maintenance efforts.32 Annual review of health behaviors should incorporate questions regarding dietary intake and exercise activity. Be mindful that major changes in life can alter the balance of a normal-weight patient and quickly lead to obesity. For example, a young woman who gained more than 100 lbs in a year was evaluated for bariatric surgery. A thorough workup failed to identify an underlying etiology until she was asked what had changed during the previous year. She revealed that she had married an abusive partner and had begun to comfort herself with food. Similarly, a change in job status (including retirement), the death of a loved one, pregnancy, or ongoing overwhelming stress can cause the person to overeat.
Health-care providers can have a positive influence on changing unhealthy habits. The Organisation for Economic Co-operation and Development recommends strong policy measures combined with individual management issues to help control the obesity epidemic. Clinicians are in a prime position to help patients understand that it is easier to keep the weight off than to take it off. It is alright to decline food if one is not hungry and to avoid centering social activities around eating. It is okay to leave food on the plate and even better to limit portions at the outset to avoid the waste.
Encourage patients to replace negative talk with positive thinking. Instruct them to monitor their weight regularly and to take corrective action when a 5-lb gain is noted. Direct them to support groups or individual therapy to address weight-maintenance issues. Teach adult patients how to serve as good weight-management and nutrition role models for their children. Research on self-regulation maintenance programs, including face-to-face meetings, Internet support groups, and quarterly newsletters indicates that face-to-face group meetings provided better outcomes for controlling weight regain than do other approaches.33
The health-care community has a responsibility to recognize and overcome the obstacles to treatment. Numerous barriers to weight-loss counseling—including time constraints, lack of training, lack of resources, lack of reimbursement, lack of confidence in the patients’ ability and/or desire to lose weight, and lack of specific guidelines for weight management—have been identified.34 Other hurdles include obese patients with manipulative characteristics and patients and families with unrealistic expectations that lead to difficult and complex family/patient dynamics.35 Limited space and special equipment required to evaluate, manage, and otherwise accommodate obese patients fosters suboptimal care. Numerous medications potentiate overdosing due to the difference between ideal-body-weight dosing requirements and actual-body-weight dosing. Understanding the pharmacokenetics of distribution, clearance, and dosing is as important in achieving therapeutic drug levels in the obese population as in the pediatric and geriatric populations.
The road to a healthy BMI represents a long journey that requires a lifelong commitment to changing dietary patterns, incorporating exercise into the daily schedule, and learning and responding to the personal cues and triggers that lead to unhealthy behaviors. Obesity is driving more of our population into hospitals and clinics with chronic conditions related to weight and failed weight-loss efforts. Stopping obesity before it occurs is a much easier course than trying to correct and reverse it.
Ms. Moore is a nurse practitioner at Central Texas Veterans Health Care System, division of cardiology, in Temple. The author has no relationships to disclose regarding the content of this article.
HOW TO TAKE THE POST-TEST: To obtain CME/CE credit, please click here after reading the article to take the post-test on myCME.com.
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All electronic documents accessed June 15, 2011.
HOW TO TAKE THE POST-TEST: To obtain CME/CE credit, please click here after reading the article to take the post-test on myCME.com.