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45: Care of the Patient Undergoing Bariatric Surgery
Theresa L. Clifford
Obesity continues to be a common health issue in the United States. In an effort to combat the serious health consequences associated with obesity, such as heart disease and type 2 diabetes, many healthcare consumers are turning to bariatric procedures to address this prevalent issue. This chapter provides a discussion regarding the health risks associated with obesity and the potential complications associated with these risks in the perianesthesia setting. The most common bariatric procedures will also be explained as well as the implications for perianesthesia nursing care.
Body mass index; obesity; bariatric; metabolic surgery; complications
Obesity among the adult population in the United States remains a pervasive issue. From 2017 to 2018, the Centers for Disease Control and Prevention reported the prevalence of adult obesity was 42.4%, or more than one in three American adults.1 The prevalence of childhood obesity is approximately 18.5% (13.7 million).2 The financial impact of obesity was estimated to be $147 billion in 2008, an average of $1429 more for the obese patient than the cost of care for those with normal weight.1
Today, weight loss surgery remains a viable treatment option for overweight patients. In 2018 approximately 252,000 bariatric surgeries were performed, indicating a slow but consistent increase in the annual number of procedures.3 The gastric sleeve resection is the most commonly performed procedure at this time. In general, the perianesthesia nurse caring for the patient with bariatric issues faces a number of physiological challenges.4
Bariatrics Branch of medicine dealing with the causes, prevention, and treatment of obesity.
Biliopancreatic Diversion (BD) Surgical procedure that involves reducing the size of the stomach, allowing food to bypass part of the small intestine to change the normal process of digestion.
Body Mass Index (BMI) A measure of body fat derived from a formula using a person’s weight and height.
Laparoscopic Adjustable Gastric Banding (LAGB) One of the most common weight loss surgical procedures, it involves placing an adjustable silicone band around the upper portion of the stomach to restrict the size of the stomach. The band is tightened by adding saline through a port placed under the skin in the abdomen.
Malabsorptive Procedures Weight loss surgeries combining the reduction of stomach size with redirection of the digestive process causing poor absorption of nutrients and calories.
Metabolic Syndrome A syndrome characterized by several common factors including abdominal obesity and insulin resistance in which the body cannot use insulin efficiently.
Morbid Obesity Generally involves a state of being 50% to 100% over normal weight, being more than 100 pounds (45.5 kg) over normal weight, having a BMI of 40 or higher, or being sufficiently overweight to severely interfere with health or normal function.
Obstructive Sleep Apnea (OSA) A sleep-disordered breathing; the risk increases with increased body weight.
Obesity A condition involving excess proportion of total body fat. A person is considered obese when his or her weight is 20% or more above normal weight.
Restrictive Procedures Weight loss surgeries reducing the stomach size, limiting the capacity of the stomach to hold food.
Roux-en-Y (RNY) Common gastric bypass surgery that divides the stomach into a small upper pouch and a much larger, lower remnant pouch, and then rearranges the small intestine into a Y configuration to enable outflow of food from the small upper stomach pouch via a Roux limb.
Vertical Sleeve Gastrectomy (VSG or LSG) Weight loss surgical procedure that creates a thin vertical sleeve of stomach using a stapling device, removing the rest of the stomach and thus limiting the amount of food eaten without causing any malabsorption.
Weight Loss Surgery (WLS) Procedures that limit the amount of food a stomach can hold, restrict the amount of food digested, or integrate a combination of both restriction and malabsorption.
The most useful anthropometric index for determination of obesity is the body mass index (BMI).5 This measurement describes the relationship between height and weight using one of the following calculations:
The higher the BMI, the greater the weight associated with a given height. Studies have demonstrated that the patient who is considered overweight and one who is considered obese usually experience minimal risks in the perioperative period.6 Underweight patients, as well as patients classified as morbidly obese, are found to have moderately increased perioperative mortality rates; however, patients who are super obese and greater have the highest incidence of mortality. Although obesity is not equally distributed across gender or race, the incidence of obesity in a given community is relevant and clinically important. Patients at risk for obesity-related complications are seen in perianesthesia services for a wide variety of conditions for a wide variety of services including bariatric and nonbariatric surgery.6 Most bariatric programs have established inclusion criteria for weight loss surgery. Generally patients must enroll in a preoperative program that involves weight management strategies with specialty nutritionists, exercise physiologists, and behavioral health consults to establish commitment and to reduce potential complications.
Preoperative evaluation of obese patients reveals that 85% have exertional dyspnea and some degree of orthopnea.7 Periodic apnea, especially when sleeping, may also be present.
Obese patients tend to develop some degree of thoracic kyphosis and lumbar lordosis because of a protuberant abdomen. In addition, the layers of fat on the chest and abdomen reduce the bellows action of the thoracic cage. The overall lung-thorax compliance is reduced and thus leads to increased elastic resistance of the system. Usually, the diaphragm is elevated, and the total work of breathing is increased as a result of the deposition of abdominal fat. Because of these factors, the oxygen cost of breathing is threefold or greater than normal even at rest.
The primary respiratory defect of obese patients is a marked reduction in the expiratory reserve volume (ERV). The reason for the decrease in ERV and other lung volumes is that the obese patient is unable to expand the chest in a normal fashion. As a result, diaphragmatic movement must account for the changes in lung volume to a much greater extent than thoracic expansion does. As discussed previously, the diaphragmatic movement is moderately limited by the anatomic changes of obesity, which account for the decreased lung volumes.
In the obese patient, the functional residual capacity (FRC) may be less than the closing capacity in the sitting and supine positions; therefore, the dependent lung zones may be effectively closed throughout the respiratory cycle. Consequently, inspired gas is distributed mainly to the upper or nondependent lung zones. The resulting mismatch of ventilation to perfusion produces systemic arterial hypoxemia. The hypoventilation and ventilation-perfusion abnormalities that contribute to systemic arterial hypoxemia also contribute to retention of carbon dioxide and thus lead to hypercarbia.
In the general population, undiagnosed obstructive sleep apnea (OSA) is common in obese patients despite awareness that increased abdominal girth is a significant risk factor.8 Reportedly more than 70% of patients undergoing weight loss surgery have been clinically diagnosed with sleep apnea. OSA can occur in patients with redundant pharyngeal tissue. OSA is characterized by excessive episodes of apnea (approximately 10 seconds), apneic episodes occurring more than five times per hour, and a 50% reduction in airflow or a reduction sufficient to lead to a 4% decrease in oxygen saturation during sleep as a result of a partial or complete upper airway obstruction. Clinically significant apnea episodes of more than five episodes in 1 hour or 30 per night result in hypoxia, hypercapnia, systemic and pulmonary hypertension, and cardiac arrhythmias. In obese patients with OSA, there is an increased risk of difficult intubations as well as postextubation complications including increased risk for reintubations and associated arrhythmias.7
Thirty pounds of fat are estimated to contain 25 miles of blood vessels, and the increased body mass in obesity leads to increased oxygen consumption and carbon dioxide production. It is not surprising that the cardiac output and the total blood volume are increased in the obese state. This increase in cardiac output is a result of an increase in stroke volume rather than an increase in heart rate; the latter usually remains normal. The transverse cardiac diameter has been shown to be greater than normal in approximately two thirds of obese patients. A linear relationship seems to exist between cardiac diameter and body weight.
Obesity has been suggested to predispose one to electrocardiographic changes. The QT interval is often prolonged, and the QRS voltage is reduced because of the increased distance between the heart and the electrodes. Finally, the likelihood of ventricular arrhythmias is increased in the obese patient. These arrhythmias are believed to be a result of myocardial hypertrophy, hypoxemia, coronary artery disease, and fatty infiltration of the conducting and pacing systems.
A positive correlation exists between an increase in body weight and increased arterial pressure. Hypertension is a known risk factor for the development of coronary artery disease. A weight gain of 28 lb (12.75 kg) can increase the systolic and diastolic blood pressure by 10 and 7 torr, respectively. Systemic hypertension is tenfold more likely in the obese patient. The increase in blood pressure is probably caused by the increased cardiac output.
Chronic heart failure, although uncommon, can occur in persons with long-standing morbid obesity with or without hypertension. It is usually characterized by high output and biventricular dysfunction with the left ventricle predominating.7 Clinically, heart failure can be difficult to diagnose because pedal edema may be chronically present.
Cerebral blood flow in obese persons does not differ significantly from that in persons of normal weight. Oxygen uptake of the brain remains normal in the obese person; however, the fraction of the total body oxygen represented in the cerebral metabolism is less than normal because the total body oxygen requirement is increased. Although the kidneys of obese subjects weigh more than those of nonobese counterparts, renal blood flow is the same as or slightly lower than that of patients of normal weight.
A number of contributing factors are associated with obesity such as environment, genetics, highly processed and energy-dense foods, lack of exercise, and ethnic culture in addition to numerous psychological and social issues. Often, eating has nothing to do with hunger. Many people eat in response to emotions such as boredom, sadness, or anger. Disordered eating may also be a symptom of depression and low self-esteem. Some individuals use food to fill emptiness, provide good feelings, and soothe job pressures and personal conflicts. Socially, obese people are perceived as lazy and lacking self-discipline and willpower, which can lead to a cycle of self-blame, guilt, shame, depression, and social withdrawal.9 Body image, along with the ability to interact with others, may be a problem for obese patients. Many bariatric patients have avoided routine medical care for fear of being judged and disrespected.
The presence of multiple skin folds can lead to impaired hygiene in the patient who may have difficulty seeing or reaching areas that need cleaning. Retained moisture on this redundant skin can lead to excoriations or rashes if not kept clean and dry. Problem areas tend to be found in the groin, perineum, or axilla; beneath the breasts; and in large skin folds. Wound infections can develop and commonly include yeast and fungi. Adipose tissue is poorly vascularized and can cause delayed wound healing.
Metabolic syndrome, also known as insulin resistance, is related to the effect of chronically high-normal serum blood glucose. The body has consistently high levels of glucose, requiring the pancreas to secrete greater and greater amounts of insulin to keep blood sugar regulated. Eventually, the cells no longer respond to insulin, and glucose begins to accumulate in the blood, leading to diabetes. Diabetes mellitus (DM) has been associated with obesity and metabolic resistance. DM is the third most prevalent preoperative pathologic condition found in obese patients. Hypertension and dyslipidemia frequently occur concurrently and in association with resistance to insulin-stimulated glucose metabolism. When these risk factors cluster, the risks for coronary heart disease (CHD), stroke, diabetes, and cardiovascular disease mortality are further increased. This clustering of risk factors is frequently but not invariably associated with obesity, particularly abdominal obesity. Insulin resistance is also associated with an unfavorable imbalance in the endothelial production of mediators that regulate platelet aggregation, coagulation, fibrinolysis, and vessel tone.
Other problems associated with clinical obesity include abnormal liver function tests, fatty infiltration of the liver (nonalcoholic steatohepatitis), gallstones, hiatal hernia, stress incontinence, and varicose veins. Gastroesophageal reflux is prevalent among the obese. Overweight patients are at higher risk for deep vein thrombosis and pulmonary emboli because of the limited or lack of mobility, stasis, and polycythemia related to chronic respiratory insufficiency. Obese individuals will also have some degree of degenerative joint disease affecting mobility. Higher body weights are also associated with a higher risk for certain cancers including endometrial, breast, prostate, and colon.
For centuries, standard diet and exercise was the usual prescription for weight loss. These approaches may be ineffective for many individuals with obesity. Considering the increase in incidence of obesity and obesity- related health concerns, weight-related issues have become a priority for population health. Multiple venues for managing weight have been established, and newer safer techniques in weight loss surgery are among the many treatment options for reducing excess body fat.
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