Management of the High-Risk Bariatric Surgery Candidate

  • Peter N. Benotti
Chapter

Abstract

The ability to recognize and quantitate risk factors affecting surgical outcomes allows for the development of risk-reducing strategies, which can be implemented during the lengthy preoperative evaluation process. This involves expanded specialty resources with expertise in lifestyle intervention, exercise training, physical rehabilitation, dietary intervention, and smoking cessation. Optimization of comorbid conditions, improvement in functional status, weight loss, and smoking cessation are all interventions that can be integrated into the preoperative program with potential for favorable influence on outcomes.

Keywords

Cholesterol Obesity Depression Nicotine Warfarin 

References

  1. 1.
    Apovian C, Cummings S, Anderson W, Borud L, Boyer K, Day K, et al. Best practice updates for multidisciplinary care in weight loss surgery. Obesity. 2009;17:871–9.PubMedCentralPubMedCrossRefGoogle Scholar
  2. 2.
    Maggard M, McGory M, Shekelle P, Ko C. Quality indicators in bariatric surgery: improving quality of care. Surg Obes Relat Dis. 2006;2:423–30.PubMedCrossRefGoogle Scholar
  3. 3.
    Santry H, Chin M, Cagney K, Alverdy J, Lauderdale D. The use of multidisciplinary teams to evaluate bariatric surgery patients from a national survey in the USA. Obes Surg. 2006;16:59–66.PubMedCrossRefGoogle Scholar
  4. 4.
    Poirier P, Alpert M, Fleisher L, Thompson P, Sugerman H, Burke L, et al. Cardiovascular evaluation and management of severely obese patients undergoing surgery: a science advisory from the American Heart Association. Circulation. 2009;120:86–95.PubMedCrossRefGoogle Scholar
  5. 5.
    Dela Cruz C, Matthay R. Role of obesity in cardiomyopathy and pulmonary hypertension. Clin Chest Med. 2009;30:509–23.PubMedCrossRefGoogle Scholar
  6. 6.
    Piper A. Obesity hyperventilation syndrome—the Big and the breathless. Sleep Med Rev. 2011;15:79–89.PubMedCrossRefGoogle Scholar
  7. 7.
    Littleton S, Mokhlesi B. The Pickwickian syndrome—obesity hypoventilation syndrome. Clin Chest Med. 2009;30:467–78.PubMedCrossRefGoogle Scholar
  8. 8.
    Barst R, McGoon M, Torbicki A, Sitbon O, Krowka M, Olschewski H, et al. Diagnosis and differential assessment of pulmonary arterial hypertension. J Am Coll Cardiol. 2004;43:40S–7.PubMedCrossRefGoogle Scholar
  9. 9.
    Chin K, Rubin L. Pulmonary arterial hypertension. J Am Coll Cardiol. 2008;51:1527–38.PubMedCrossRefGoogle Scholar
  10. 10.
    Clinical Issues Committee ASMBS. Peri-operative management of obstructive sleep apnea. Surg Obes Relat Dis. 2012;8:e27–32.CrossRefGoogle Scholar
  11. 11.
    American Thoracic Society. ATS statement: guidelines for the six minute walk test. Am J Respir Crit Care Med. 2002;166:111–7.CrossRefGoogle Scholar
  12. 12.
    The American society for Metabolic and Bariatric Surgery Clinical Issues Committee. ASMBS updated position statement on prophylactic measures to reduce the risk of venous thromboembolism in bariatric surgery patients. Surg Obes Relat Dis. 2013;9:493–7.CrossRefGoogle Scholar
  13. 13.
    Overby D, Kohn G, Cahan M, et al. Prevalence of thrombophilias in patients presenting for bariatric surgery. Obes Surg. 2009;19:1278–85.PubMedCrossRefGoogle Scholar
  14. 14.
    Birkmeyer N, Finks J, Carlin A, Chengelis D, Krause K, Hawasli A, et al. Comparative effectiveness of unfractionated and Low-molecular-weight heparin for prevention of venous thromboembolism following bariatric surgery. Arch Surg. 2012;147:994–8.PubMedCrossRefGoogle Scholar
  15. 15.
    Bechtel P, Boorse R, Rovito P, Harrison T, Hong J. Warfarin users prone to coagulopathy in first 30 days after hospital discharge from gastric bypass. Obes Surg. 2013;23:1515–9.PubMedCrossRefGoogle Scholar
  16. 16.
    Baron T, Kamath P, McBane R. Management of antithrombotic therapy in patients undergoing invasive procedures. N Engl J Med. 2013;368:2113–24.PubMedCrossRefGoogle Scholar
  17. 17.
    Qadan M, Weller E, Gardner S, Maldonado C, Fry D, Polk H. Glucose and surgical sepsis: a study of underlying immunologic mechanisms. J Am Coll Surg. 2010;210:966–74.PubMedCrossRefGoogle Scholar
  18. 18.
    Ramos M, Khalpey Z, Lipsitz S, Steinberg J, Panizales M, Zinner M, et al. Relationship of perioperative hyperglycemia and postoperative infections in patients who undergo general and vascular surgery. Ann Surg. 2008;248:585–91.PubMedGoogle Scholar
  19. 19.
    Jackson R, Amdur R, White J, Macsata R. Hyperglycemia Is associated with increased risk of morbidity and mortality after colectomy for cancer. J Am Coll Surg. 2012;214:68–80.PubMedCrossRefGoogle Scholar
  20. 20.
    NICE-SUGAR Study Investigators. Intensive versus conventional glucose control in critically Ill patients. N Engl J Med. 2009;360:1283–97.CrossRefGoogle Scholar
  21. 21.
    Donohoe C, Feeney C, Carey M, Reynolds J. Perioperative evaluation of the obese patient. J Clin Anesth. 2011;23:575–86.PubMedCrossRefGoogle Scholar
  22. 22.
    Turner P, Saager L, Dalton J, Abd-Elsayed A, Roberman D, Melara P, et al. A nomogram for predicting surgical complications in bariatric surgery patients. Obes Surg. 2011;21:655–62.PubMedCrossRefGoogle Scholar
  23. 23.
    Khuri S, Daley J, Henderson W, Hur K, Demakis J, Aust J, et al. The Department of Veterans Affairs’ NSQIP: the first national validated, outcome-based risk-adjusted, and peer controlled program for the measurement and enhancement of the quality of surgical care. Ann Surg. 1998;228:491–507.PubMedCentralPubMedCrossRefGoogle Scholar
  24. 24.
    Winter J, Cameron J, Yeo C, Babatunde a, Lillemoe K, Campbell K, et al. Biochemical markers predict morbidity and mortality after pancreaticoduodenectomy. J Am Coll Surg. 2007;204: 1029–38.PubMedCrossRefGoogle Scholar
  25. 25.
    Ernst B, Thurnheer M, Schmid S, et al. Evidence for the necessity to systematically assess micronutrient status prior to bariatric surgery. Obes Surg. 2009;19:66–73.PubMedCrossRefGoogle Scholar
  26. 26.
    Flancbaum L, Belsey S, Drake V, et al. Preoperative nutritional status of patients undergoing Roux-en-Y gastric bypass for morbid obesity. J Gastrointest Surg. 2006;10:1033–7.PubMedCrossRefGoogle Scholar
  27. 27.
    Hall J. Nutritional assessment of surgery patients. J Am Coll Surg. 2006;202:837–43.PubMedCrossRefGoogle Scholar
  28. 28.
    Marchesini G, Moscatiello S, Di Domizio S, Forlani G. Obesity-associated liver disease. J Clin Endocrinol Metab. 2008;93:S74–80.PubMedCrossRefGoogle Scholar
  29. 29.
    Brolin R, Bradley L, Taliwal R. Unsuspected cirrhosis discovered during elective obesity operations. Arch Surg. 1998;133:84–8.PubMedCrossRefGoogle Scholar
  30. 30.
    Mosko J, Nguyen G. Increased perioperative mortality following bariatric surgery among patients with cirrhosis. Clin Gastroenterol Hepatol. 2011;9:897–901.PubMedCrossRefGoogle Scholar
  31. 31.
    King W, Belle S, Eid G, Dakin G, Inabnet W, Mitchell J, et al. Physical activity levels of patients undergoing bariatric surgery in the longitudinal assessment of bariatric surgery. Surg Obes Relat Dis. 2008;4:721–8.PubMedCentralPubMedCrossRefGoogle Scholar
  32. 32.
    King W, Engel S, Elder K, Chapman W, Eid G, Wolfe B, et al. Walking capacity of bariatric surgery candidates. Surg Obes Relat Dis. 2012;8:48–61.PubMedCentralPubMedCrossRefGoogle Scholar
  33. 33.
    Stegen S, Derave W, Calders P, Van Laethem C, Pattyn P. Physical fitness in morbidly obese patients: effect of gastric bypass surgery and exercise training. Obes Surg. 2011;21:61–70.PubMedCrossRefGoogle Scholar
  34. 34.
    King W, Hsu J, Belle S, Courcoulas A, Eid G, Flum D, et al. Pre- to postoperative changes in physical activity: report from the longitudinal assessment of bariatric surgery-2 (LABS-2). Surg Obes Relat Dis. 2012;8:522–32.PubMedCentralPubMedCrossRefGoogle Scholar
  35. 35.
    Bond D, Evans R, DeMaria E, Wolfe L, Meador J, Kellum J, et al. Physical activity and quality of life improvements before obesity surgery. Am J Health Behav. 2006;30:422–34.PubMedCrossRefGoogle Scholar
  36. 36.
    Bond D, Evans R, DeMaria E, Wolfe L, Meador J, Kellum J, et al. Physical activity stage of readiness predicts moderate-vigorous physical activity participation among morbidly obese gastric bypass surgery candidates. Surg Obes Relat Dis. 2006;2:128–32.PubMedCrossRefGoogle Scholar
  37. 37.
    Warburton D, Nicol C, Bredi S. Health benefits of physical activity: the evidence. Can Med Assoc J. 2006;174:801–9.CrossRefGoogle Scholar
  38. 38.
    McCullough P, Gallagher M, deJong A, Sandberg K, Trivax J, Alexander D, et al. Cardiorespiratory fitness and short-term complications after bariatric surgery. Chest. 2006;130: 517–25.PubMedCrossRefGoogle Scholar
  39. 39.
    Goodpaster B, DeLany J, Otto A, Kuller L, Vockley J, South-Paul J, et al. Effects of diet and physical activity interventions on weight loss and cardiometabolic risk factors in severely obese adults. JAMA. 2010;304:1795–802.PubMedCentralPubMedCrossRefGoogle Scholar
  40. 40.
    Carli F, Charlebois P, Stein B, Feldman L, Zavorsky G, Kim D, et al. Randomized clinical trial of prehabilitation in colorectal surgery. Br J Surg. 2010;97:1187–97.PubMedCrossRefGoogle Scholar
  41. 41.
    Mayo N, Feldman L, Scott S, Zavorsky G, Kim D, Charlebois P, et al. Impact of preoperative change in physical function on postoperative recovery: argument supporting prehabilitation for colorectal surgery. Surgery. 2011;150:505–14.PubMedCrossRefGoogle Scholar
  42. 42.
    Jones L, Peddle C, Eves N, Haykowsky M, Courneya K, Mackey J, et al. Effects of presurgical exercise training on cardiorespiratory fitness among patient undergoing thoracic surgery for malignant lung lesions. Cancer. 2007;110:590–8.PubMedCrossRefGoogle Scholar
  43. 43.
    Villareal D, Chode S, Parimi N, Sinacore D, Hilton T, Armanento-Villareal R, et al. Weight loss, exercise, or both and physical function in obese older adults. N Engl J Med. 2011;364:1218–29.PubMedCentralPubMedCrossRefGoogle Scholar
  44. 44.
    Bond D. Comment on: walking capacity of bariatric surgery candidates. Surg Obes Relat Dis. 2012;8:59–61.PubMedCrossRefGoogle Scholar
  45. 45.
    Livingston E, Arterburn D, Schifftner T, Henderson W, DePalma R. National surgery quality improvement program analysis of bariatric operations: modifiable risk factors contribute to bariatric surgical adverse outcomes. J Am Coll Surg. 2006;203:625–33.PubMedCrossRefGoogle Scholar
  46. 46.
    Finks J, Kole K, Yenumula P, English W, Krause K, Carlin A, et al. Predicting risk for serious complications with bariatric surgery. Results from the Michigan Bariatric Surgery Collaborative. Ann Surg. 2011;254:633–40.PubMedCrossRefGoogle Scholar
  47. 47.
    Lautz D, Jackson T, Clancy K, Escareno C, Schifftner T, Henderson G, et al. Bariatric operations in veterans affairs and selected university medical centers: results of a patient safety study. J Am Coll Surg. 2007;204:1261–72.PubMedCrossRefGoogle Scholar
  48. 48.
    Zhang W, Mason E, Renquist K, Zimmerman B. Factors influencing survival following surgical treatment of obesity. Obes Surg. 2005;15:43–50.PubMedCrossRefGoogle Scholar
  49. 49.
    Gonzalez R, Haines K, Nelson L, Gallagher S, Murr M. Predictive factors of thromboembolic events in patients undergoing Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2006;2:30–6.PubMedCrossRefGoogle Scholar
  50. 50.
    Sweetland S, Parkin L, Balkwill A, Green J, Reeves G, Beral V, et al. Smoking, Surgery, and venous thromboembolism risk in women: United Kingdom Cohort Study. Circulation. 2013;127:1276–82.PubMedCrossRefGoogle Scholar
  51. 51.
    Wilson J, Romangnuolo J, Byrne K, Morgan K, Wilson F. Predictors of endoscopic findings after Roux-en-Y gastric bypass. Am J Gastroenterol. 2006;101:2194–9.PubMedCrossRefGoogle Scholar
  52. 52.
    Sorensen L. Wound healing and infection in surgery: the pathophysiological impact of smoking, smoking cessation, and nicotine replacement therapy. Ann Surg. 2012;255:1069–79.PubMedCrossRefGoogle Scholar
  53. 53.
    Thomsen T, Tonnesen H, Moller A. Effect of preoperative smoking cessation interventions on postoperative complications and smoking cessation. Br J Surg. 2009;96:451–61.PubMedCrossRefGoogle Scholar
  54. 54.
    Warner M, Offord K, Warner M, Lennon R, Conover A, Jansson-Schumacher U. Role of preoperative cessation of smoking and other factors in postoperative pulmonary complications: a blinded prospective study of coronary artery bypass patients. Mayo Clin Proc. 1989;64: 609–16.PubMedCrossRefGoogle Scholar
  55. 55.
    Bluman L, Mosca L, Newman N, Simon D. Preoperative smoking habits and postoperative pulmonary complications. Chest. 1998;113:883–9.PubMedCrossRefGoogle Scholar
  56. 56.
    Moller A, Villebro N, Pedersen T, Tonnesen H. Effect of preoperative smoking intervention on postoperative complications: a randomized clinical trial. Lancet. 2002;359:114–7.PubMedCrossRefGoogle Scholar
  57. 57.
    Mechanick J, Kushner R, Sugerman H, Gonzalez-Campoy M, Collazo-Clavell M. The Obesity Society, and American Society for Metabolic and Bariatric Surgery Medical Guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Surg Obes Relat Dis. 2008;4:S109–84.PubMedCrossRefGoogle Scholar
  58. 58.
    Mechanic J, Youdim A, Joned D, Garvey T, Hurley D, MacMahon M, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient – 2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic and Bariatric Surgery. Surg Obes Relat Dis. 2013;9:150–9.CrossRefGoogle Scholar
  59. 59.
    Windover A. Tobacco use in bariatric patients. Bariatric Times. 2013;10(1):8–11.Google Scholar
  60. 60.
    Fiore M, Baker T. Treating smokers in the health care setting. N Engl J Med. 2011;365: 1222–31.PubMedCrossRefGoogle Scholar
  61. 61.
    Levinson W, Cohen M, Brady D, Duffy F. To change or not to change: “Sounds like you have a dilemma”. Ann Intern Med. 2001;135:386–91.PubMedCrossRefGoogle Scholar
  62. 62.
    Blackburn G. Effect of degree of weight loss on health benefits. Obes Res. 1995;3:211s–6.PubMedCrossRefGoogle Scholar
  63. 63.
    Yanovski S, Yanovski J. Obesity. N Engl J Med. 2002;346:591–602.PubMedCrossRefGoogle Scholar
  64. 64.
    Collins J, McCloskey C, Titchner R, Goodpaster B, Hoffman M, Hauser D, et al. Preoperative weight loss in high-risk superobese bariatric patients: a computed tomography-based analysis. Surg Obes Relat Dis. 2011;7:480–5.PubMedCrossRefGoogle Scholar
  65. 65.
    Wong C, Byrne N, O’Moore-Sullivan T, Hills A, Prins J, Marwick T. Effect of weight loss due to lifestyle intervention on subclinical cardiovascular dysfunction in obesity (body mass index >30 kg/m.2. Am J Cardiol. 2006;98:1593–8.PubMedCrossRefGoogle Scholar
  66. 66.
    Van Nieuwenhove Y, Dambrauskas Z, Campillo-Soto A, ven Dielen F, Wiezer R, Janssen I, et al. Preoperative very low-calorie diet and operative outcome after laparoscopic gastric bypass. A randomized multicenter study. Arch Surg. 2011;146:1300–5.PubMedCrossRefGoogle Scholar
  67. 67.
    Alvarado R, Alami R, Hsu G, Safadi B, Sanchez B, Morton J, et al. The impact of preoperative weight loss in patients undergoing laparoscopic roux-en-Y gastric bypass. Obes Surg. 2005;15:1282–6.PubMedCrossRefGoogle Scholar
  68. 68.
    Still C, Benotti P, Wood G, Gerhard G, Petrick A, Reed M, et al. Outcomes of preoperative weight loss in high-risk patients undergoing gastric bypass surgery. Arch Surg. 2007;142: 994–8.PubMedCrossRefGoogle Scholar
  69. 69.
    Colles S, Dixon J, Marks P, Strauss B, O’Brien P. Preoperative weight loss with a very low energy diet: quantitation of changes in liver and abdominal fat by serial imaging. Am J Clin Nutr. 2006;84:304–11.PubMedGoogle Scholar
  70. 70.
    Lewis M, Phillips M, Slavotinek J, Kow L, Thompson C, Toouli J. Change in liver size and fat content after treatment with optifast very low calorie diet. Obes Surg. 2006;16:697–701.PubMedCrossRefGoogle Scholar
  71. 71.
    Alami R, Morton J, Schuster R, Sanchez B, Peters A, Curet M. Is there a benefit to preoperative weight loss in gastric bypass benefits? A prospective randomized trial. Surg Obes Relat Dis. 2007;3:141–6.PubMedCrossRefGoogle Scholar
  72. 72.
    Reiss K, Baker M, Lambert P, Mathiason M, Kothari S. Effect of preoperative weight loss on laparoscopic gastric bypass outcomes. Surg Obes Relat Dis. 2008;4:704–8.CrossRefGoogle Scholar
  73. 73.
    Solomon H, Liu G, Alami R, Morton J, Curet M. Benefits to patients choosing preoperative weight loss in gastric bypass surgery: new results of a randomized trial. J Am Coll Surg. 2009;208:241–5.PubMedCrossRefGoogle Scholar
  74. 74.
    Benotti P, Still C, Wood C, Akmal Y, King H, El Arousy H, et al. Preoperative weight loss before bariatric surgery. Arch Surg. 2009;144:1150–5.PubMedCrossRefGoogle Scholar
  75. 75.
    Tarnoff M, Rodriguez L, Escalona A, Ramos A, Neto M, Alamo M, et al. Open Label, prospective randomized controlled trial of an endoscopic duodenal-jejunal bypass sleeve versus low calorie diet for pre-operative weight loss in bariatric surgery. Surg Endosc. 2009;23: 650–6.PubMedCrossRefGoogle Scholar
  76. 76.
    Zerrweck C, Maunoury V, Caiazzo R, Branche J, Dezfoulian G, Bulois P, et al. Preoperative weight loss with intragastric balloon decreases the risk of significant adverse outcomes of laparoscopic gastric bypass in super-super obese patients. Obes Surg. 2012;22:777–82.PubMedCrossRefGoogle Scholar
  77. 77.
    Busetto L, Segato G, De Luca M, Bortolozzi E, MacCari T, Magon A, et al. Preoperative weight loss by intragastric balloon in super-obese patients treated with laparoscopic gastric banding. Obes Surg. 2004;14:671–6.PubMedCrossRefGoogle Scholar
  78. 78.
    Alfalah H, Bulois P, Ghazai F, Jany T, Arnalsteen L, Romon M, et al. Intragastric balloon for preoperative weight reduction in candidates for laparoscopic gastric bypass with massive obesity. Obes Surg. 2006;16:147–50.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Peter N. Benotti
    • 1
  1. 1.Obesity Institute, Geisinger Medical CenterSoutholdUSA

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