Perioperative Nursing Care of the Bariatric Surgical Patient

Article Outline

• ABSTRACT
• Defining Overweight and Obesity
  • Fat distribution
  • Calculating body mass index
• Obesity-Associated Health Risks
• History of Bariatric Surgery
• Common Bariatric Procedures
  • Roux-en-Y gastric bypass
  • The LAGB procedure
  • Vertical-banded gastroplasty
  • Biliopancreatic diversion and duodenal Switch
• Risks and Complications of Bariatric Surgery
• Patient Selection
• Initial Evaluation and Preoperative Preparation
  • Internal medicine clearance
  • Psychiatric evaluation
  • Insurance preauthorization
  • Preoperative expectations of the patient
  • Nutritional instructions
  • Smoking cessation
• Preoperative Nursing Assessment of the Bariatric Patient
• Anesthesia Care of the Bariatric Patient
  • Medication absorption concerns
  • Cardiovascular and respiratory concerns
  • Aspiration risk
  • Airway challenges
• Intraoperative Nursing Care of the Bariatric Patient
  • Respiratory system
    • Interventions
  • Cardiac system
    • Interventions
  • Vascular system
    • Interventions
  • Musculoskeletal and nervous systems
    • Interventions
  • Gastrointestinal and urinary systems
    • Interventions
  • Psychosocial system
    • Interventions
• Preventing Potential Complications
  • Hypothermia
    • Interventions
  • Intra-abdominal injury or anastomosis leakage
    • Interventions
  • Retained foreign body
    • Interventions
  • Postoperative infection
    • Interventions
  • Anesthetic emergence complications
    • Interventions
• Preparing for Transfer to the PACU
• The PACU Phase
• Medical-Surgical Unit Care
• Long-Term Postoperative Care
  • Postoperative medication instructions
  • Postoperative diet
• Outcomes
• Pregnancy After Bariatric Surgery
• Conclusion
• Examination
  • Perioperative Nursing Care of the Bariatric Surgical Patient
    • Purpose/Goal
    • Behavioral Objectives
    • Questions
• Answer Sheet
  • Perioperative Nursing Care of the Bariatric Surgical Patient
• Learner Evaluation
  • Perioperative Nursing Care of the Bariatric Surgical Patient
    • Purpose/Goal
    • Objectives
    • Content
    • Test Questions/Answers
    • Learner Input
• References
• Copyright

ABSTRACT 

APPROXIMATELY TWO-THIRDS of the US population is overweight or obese. The effects of the comorbidities that accompany obesity often are severe and can be life threatening over time. Currently, the most effective and sustainable method of substantial weight loss is bariatric surgery. Bariatric surgery also has been successful in reversing comorbidities.

THE BENEFITS, RISKS, AND COMPLICATIONS of common weight-loss surgical procedures (eg, Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, vertical-banded gastroplasty, biliopancreatic diversion and duodenal switch) are discussed.

THE HEALTH CARE FIELD OF BARIATRICS is growing rapidly. More information is needed to support and guide changes in current standards of practice to better meet the needs of this patient population. AORN J 88 (July 2008) 30–54. © AORN, Inc, 2008.

Approximately 60% of the US population is overweight and 30.5% of the population is obese.¹, ² Obesity ranks second to cigarette smoking as a preventable cause of death in the United States.³ Approximately 300,000 adult deaths each year are attributable to unhealthy diets, physical inactivity, and sedentary behavior.⁴ The prevalence of obesity and overweight has steadily increased in both genders, all ages, all racial and ethnic groups, all educational levels, and all geographical locations across the United States.⁵

As the prevalence of obesity and overweight has increased, so have related direct and indirect health care costs.⁴ Direct health care costs refer to preventive, diagnostic, and treatment services, such as physician visits, medications, and hospital and nursing home care. Indirect costs are the value of wages lost by people unable to work because of illness or disability, as well as the value of future earnings lost because of premature death. The total annual cost of overweight and obesity is estimated to be $117 billion, with direct costs of $61 billion and indirect costs of $56 billion.⁴ This is comparable to the health care costs for cigarette smoking.⁴

Currently, the most effective means of losing substantial weight and maintaining that weight loss is bariatric surgery.⁶, ⁷, ⁸ The term bariatric comes from the Greek words baros (ie, weight) and iatreia (ie, medical treatment). Bariatrics is the branch of medicine concerned with the prevention and control of obesity and allied diseases.⁹ Bariatric surgery is gastrointestinal surgery that alters the normal digestive process. The number of bariatric surgical procedures is increasing steadily each year, with approximately 144,000 surgeries being performed in 2004.¹⁰, ¹¹ The success of weight loss after bariatric surgery has resulted in greater acceptance of surgery as a treatment for morbid obesity.

In 2006, the Centers for Medicare & Medicaid Services (CMS) officially recognized obesity as a disease and bariatric surgical procedures as an allowable benefit, providing opportunities for financial support to obese patients for obesity related medical and surgical treatments.¹² Medical attempts at weight loss have a high long-term failure rate. Even if these approaches initially are successful, results from medical weight-loss treatments usually are not durable, do not result in a decrease of weight-related health problems, and do not improve survival rates.¹³ Pharmaceutical treatment regimens also have been largely unsuccessful, with relatively low levels of average excess weight loss maintained over time. Bariatric surgery has been successful in the treatment of morbid obesity by achieving both weight loss and reversal of comorbidities.¹⁴

Caring for obese patients has created a new area of learning needs for health care professionals. Both patients and health care providers must be educated about the risks and complications associated with bariatric surgery. Policies and procedures are needed to guide health care providers who are caring for these patients. Gastric bypass procedures should be considered major surgery because they are performed on a high-risk population.¹⁵ For example, 16 patients died after weight-loss surgery in Massachusetts between March 1, 2003, and October 31, 2004.¹⁵

Sepsis and pulmonary emboli were contributing factors or the cause of death in 10 out of 16 cases. The number one trend noted in the review of all 16 mortalities was knowledge-based deficits of caregivers.^15(p1)

As a result of these deaths, the Massachusetts Department of Public Health Betsy Lehman Center for Patient Safety and Medical Error Reduction Expert Panel on Bariatric Surgery reviewed all medical literature available on bariatric surgery and published best practice guidelines for clinicians and facilities performing such procedures.¹⁶ Despite these efforts, there remains a need for better education of caregivers who are treating the increasing number of bariatric surgical patients. The purpose of this article is to assist perioperative nurses in providing safe and appropriate care for bariatric patients.

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Defining Overweight and Obesity 

The term overweight refers to an excess of body weight compared to set standards. The excess weight may come from muscle, bone, fat, water, or any combination of these. The term obesity refers specifically to having an abnormally high proportion of fat. A person can be overweight without being obese, such as an athlete who has developed significant muscle mass.¹⁷, ¹⁸

Fat distribution 

Typically, fat distribution is different in men and women, although either type of fat distribution can be found in either gender. Central obesity or android distribution of upper body fat (ie, apple shape) is the predominant type of fat distribution in men. Conversely, women typically exhibit a lower body or gynoid distribution of fat (ie, pear shape).

Calculating body mass index 

Levels of obesity can be estimated using a patient's height and weight. Body mass index (BMI) has become the medical standard to measure overweight and obesity. Although BMI cannot distinguish between muscle and body fat, this mathematical calculation generally is a good indicator of obesity and is closely associated with measures of body fat. It also predicts the development of health problems related to excess weight; however, if a person (eg, an older adult) loses muscle mass, the BMI measurement may indicate a weight is healthy when in fact it is not.¹⁸, ¹⁹

Although sources differ, levels of obesity have been categorized based on BMI (Table 1). The following calculations can be used to determine a person's BMI:

Table 1. Weight Categories by Body Mass Index¹

1 AORN bariatric surgery guideline. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2008:68.

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Obesity-Associated Health Risks 

A number of medical comorbid conditions often accompany obesity (Table 2). The effects of these conditions can be severe and, over time, can be life threatening for a person who is obese. There has been a general shift in medical practice from focusing on the comorbid conditions that accompany obesity to focusing on treating obesity as the fundamental problem because most comorbidities significantly improve or resolve with resolution of the obesity. A weight loss of 5% to 10% can significantly improve health by lowering blood pressure and cholesterol levels.¹⁸ A recent study has shown that a modest (eg, 5% to 7%) excess body weight loss can prevent type 2 diabetes in people at high risk for the disease.¹⁸

Table 2. Comorbid Conditions that Often Accompany Obesity¹, ², ³

1 Understanding adult obesity. Weight-Control Information Network. US Department of Health and Human Services. http://win.niddk.nih.gov/publications/understanding.htm. Accessed May 20, 2008.

2 AORN bariatric surgery guideline. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2008:67–85.

3 Do you know the health risks of being overweight. Weight-Control Information Network. US Department of Health and Human Services. http://win.niddk.nih.gov/publications/health_risks.htm. Accessed May 20, 2008.

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History of Bariatric Surgery 

In the 1950s, bariatric surgery began to evolve as surgeons observed that patients who had short bowel syndrome lost weight as a result of inadequate nutrition. The initial procedures developed relied primarily on inducing macronutrient malabsorption by bypassing long segments of the small bowel. The jejunoileal bypass was one such procedure developed at the University of Minnesota, Minneapolis.²⁰ Such procedures subsequently fell out of favor as their significant side effects became known over time. These procedures are of only historical interest and are no longer performed.²¹

In the 1960s, Edward E. Mason, MD, and C. Ito, MD,²² developed the gastric bypass procedure. They observed that women who had undergone a partial gastrectomy for peptic ulcer disease tended to remain underweight and had difficulty gaining weight. The procedure involved creating a small gastric pouch that then connected to a segment of jejunum, thus restricting oral intake as well as creating some malabsorption. The initial procedure involved a Billroth II connection to the small bowel. This was modified over subsequent decades to a Roux-en-Y configuration, thus giving rise to the Roux-en-Y gastric bypass (RYGBP), which became and remains the most popular bariatric surgical procedure performed in the United States.

In the 1970s, the biliopancreatic diversion (BPD) was developed in Genoa, Italy, by Nicola Scopinaro, MD, as a malabsorptive procedure that was safer than the jejunoileal bypass.²³ This procedure has been reported to result in 70% excess body weight loss and remains a popular procedure in Europe.²³

Also in the 1970s, the gastroplasty was developed as an alternative to the RYGBP, and this procedure became more feasible with the availability of mechanical staplers. The initial procedures involved creating a horizontal gastroplasty and leaving a segment of the staple line open to allow passage of food, but these procedures resulted in poor, long-term weight loss. Subsequently, the gastric pouch was modified to lie in a vertical direction.²⁴ The vertical-banded gastroplasty produced good short-term weight loss, but over time, patients developed significant problems with regaining weight or gastroesophageal reflux,²⁵ and as a result this procedure also has fallen out of favor.

In the 1980s, Hess modified the BPD to the duodenal switch configuration, to avoid the development of gastric ulcers seen with BPD.²⁶ The gastric restriction of the duodenal switch was created in the form of a sleeve gastrectomy, leaving the lesser curve of the stomach intact. The malabsorptive component of the procedure remained the same. This procedure also continues to be a popular alternative for patients and has high reported and durable weight-loss results.

Since the 1970s, a number of procedures have been developed that involve banding the stomach to induce gastric restriction.²⁷ In 1986, Lubomyr Kuzmak, MD,²⁸ devised a band with an inflatable balloon on its inner aspect connected to a small reservoir under the skin, which allowed the band to be adjusted over time.

In the 1990s, with the development and rising prevalence of laparoscopic surgical approaches, the laparoscopic RYGBP and laparoscopic adjustable gastric band (LAGB) procedure were developed. The LAGB procedure subsequently became a very popular primary weight-loss procedure in Europe and Australia.²⁹, ³⁰ In June 2001, it was approved by the US Food and Drug Administration for use in the United States.

Currently, a number of procedures are in various levels of development. Sleeve gastrectomy, initially a stage of the duodenal switch procedure, now is attracting increasing interest as a stand-alone primary weight-loss procedure.³¹ This may prove to be an alternative for those who qualify as bariatric surgical candidates but are not good candidates for a RYGBP or LAGB procedure.³² Gastric pacing as a weight-loss procedure also has been studied,³³, ³⁴ and most recently, there is interest in vagal pacing. An endoscopically implanted intragastric balloon had poor initial results but has since been modified and is again in clinical trials.¹² Primary endoscopic procedures also are under development as the needed technology becomes available.

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Common Bariatric Procedures 

Current surgical procedures achieve weight loss by making the stomach smaller (ie, restrictive procedures); bypassing portions of the small bowel to limit absorption of calories and nutrients (ie, malabsorptive procedures); or a combination of these. Commonly performed bariatric surgical procedures include the RYGBP, the LAGB procedure, vertical-banded gastroplasty, and biliopancreatic diversion (BPD) with duodenal switch (DS).

The RYGBP and BPD/DS are combination procedures that work both through restrictive and malabsorptive mechanisms. The reliance on malabsorption, however, is much greater for the BPD/DS. The LAGB is a restrictive procedure, but it has a distinct advantage over previous restrictive procedures in its adjustability. The vertical-banded gastroplasty is a procedure that had good short-term results in terms of weight loss, but a high rate of long-term weight regain. This procedure has largely been replaced by other procedures with better long-term results and remains a procedure that currently is performed only when other procedures are not technically possible or are not advisable.³⁵

Roux-en-Y gastric bypass 

The RYGBP is the most commonly practiced bariatric procedure in the United States.¹³, ¹⁶, ¹⁹, ³⁵ A small pouch at the superior stomach is created to restrict food intake. This is joined to a limb of jejunum (ie, the Roux limb), which then is joined downstream with the limb of jejunum coming from the duodenum (ie, the pancreaticobiliary limb). This forms the “Y” shape of the Roux-en-Y configuration (Figure 1). This configuration results in food passing down the Roux limb without being digested, since most of the digestive juices are secreted in the lower stomach or come into the duodenum at the ampulla. The enteral stream then does not start to get digested until it reaches the place where the Roux limb and the pancreaticobiliary limb meet. As a result, less small intestine length is available for absorption of nutrients, resulting in some degree of malabsorption. Some surgeons lengthen the Roux or pancreaticobiliary limbs or both to induce more malabsorption (ie, long-limb bypass). The procedure can be performed through an open incision, but increasingly is performed laparoscopically.

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• Figure 1. 

  Roux-en-Y gastric bypass is restrictive and malabsorptive. (Figures 1-3 reprinted from Ferraro DR. Laparoscopic adjustable banding for morbid obesity. AORN J. 2003;77(5):926, with permission from AORN, Inc, Denver, CO.)

The LAGB procedure 

The LAGB is an inflatable silicone band that is placed around the upper stomach (Figure 2).¹³, ¹⁶, ¹⁹, ³⁵ Tubing from the band communicates to the lumen of the balloon and is connected to a subcutaneous port, which can be accessed by a non-coring needle. After the LAGB is placed, it is allowed to heal into place for a period of time, and then is adjusted by injection of saline into the port, which constricts the stomach. Over time, this forms a small gastric pouch above the LAGB. The constriction can be adjusted tighter or looser as dictated by how the much restriction the patient is experiencing, how much reduction in appetite he or she is experiencing, and how the weight loss is progressing.

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• Figure 2. 

  Gastric banding systems are adjustable and reversible and can be placed laparoscopically.

Vertical-banded gastroplasty 

This procedure had been the most common, purely restrictive surgical procedure for weight control.¹³, ¹⁶, ¹⁹, ³⁵ A small stomach pouch is created using staples and a band (Figure 3). Both polypropylene mesh bands and silastic rings have been used to prevent stretching of the newly created stomach outlet.

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• Figure 3. 

  Vertical banded gastroplasty creates a tubular stomach that is restrictive. Note the direction of food flow.

Biliopancreatic diversion and duodenal Switch 

The BPD/DS is a combination procedure that works by inducing both gastric restriction as well as malabsorption.¹³, ¹⁶, ¹⁹, ³⁵ In the duodenal switch, the restrictive portion is from a sleeve gastrectomy, which involves resecting a significant portion of the stomach, and leaving a narrow vertical tube with the pylorus intact (Figure 4). This modification of anatomy decreases the incidence of anastomotic ulcers because the duodenum is more tolerant of gastric acid than the small intestine. The BPD/DS restricts oral intake, but allows patients to eat larger volumes than an RYGBP. Just beyond the pylorus, the duodenum is divided and the proximal segment is anastomosed to a segment of ileum, which becomes the “alimentary channel.” This segment then is anastomosed to the segment of intestine coming from the duodenum (ie, pancreaticobiliary channel) at a spot approximately 50 cm to 100 cm from the ileocecal valve. This leaves a very short common channel in which food is digested and absorbed.

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• Figure 4. 

  Biliopancreatic diversion with duodenal switch and sleeve gastrectomy. (Reprinted from Graling P, Elariny H. Perioperative care of the patient with morbid obesity. AORN J. 2003; 77(4):816, with permission from AORN, Inc, Denver, CO.)

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Risks and Complications of Bariatric Surgery 

Table 3 presents the benefits, disadvantages, and potential complications of common bariatric procedures. The risks of bariatric surgical procedures have attracted significant interest in the medical community,³⁶, ³⁷ as well as in the popular press. The risks associated with the procedures are variable and procedure-specific (Table 4). The incidence of the risks also is changing as practitioners better document outcomes. This has been the result of the Bariatric Centers of Excellence Programs sponsored by the American Society for Metabolic & Bariatric Surgery (ASMBS)³⁸ and by the American College of Surgeons.³⁹ These programs have developed databases that will provide more accurate data on the true risks of bariatric procedures going forward.

Table 3. Benefits, Disadvantages, and Potential Complications of Common Bariatric Procedures¹, ², ³, ⁴, ⁵

1 Commonwealth of Massachusetts Betsy Lehman Center for Patient Safety and Medical Error Reduction Expert Panel on Weight Loss Surgery: executive report. Obes Res. 2005;13(2):205–305.

2 Graling P, Elariny H. Perioperative care of the patient with morbid obesity. AORN J. 2003;77(4):802–824.

3 AORN bariatric surgery guideline. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2008:67–85.

4 Gastrointestinal surgery for severe obesity. Weight-Control Information Network. US Department of Health and Human Services. http://win.niddk.nih.gov/publications/gastric.htm. Accessed May 20, 2008.

5 Gregory Crum BS. Practicing safe care of the bariatric population. Perioperative Nursing Clinics. 2006;1(1):67–71.

Table 4. Risks of Common Bariatric Procedures¹, ², ³, ⁴

1 Gastrointestinal surgery for severe obesity. Weight-Control Information Network. US Department of Health and Human Services. http://win.niddk.nih.gov/publications/gastric.htm. Accessed May 20, 2008.

2 AORN bariatric surgery guideline. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2008:67–85.

3 Ferraro DR. Laparoscopic adjustable gastric banding for morbid obesity. AORN J. 2003;77 (5):923–944.

4 Graling P, Elariny H. Perioperative care of the patient with morbid obesity. AORN J. 2003;77(4):802–824.

Numerous factors increase the risks of surgery. Predictors of technical difficulty during surgery include android obesity; the presence of hepatomegaly, which usually is a result of fatty liver disease; and excessive abdominal girth.⁴⁰ Even though they are obese, bariatric patients often are malnourished and have protein deficiencies, which lead to poor wound healing. Obese patients also are prone to venous ulcers, varicose veins, and peripheral edema, which increase chances of poor wound healing.

Some patients report an intolerance to alcohol after having a gastric bypass.⁴¹, ⁴² Hagedorn et al⁴¹ found that alcohol metabolism was significantly different between postgastric bypass patients and control participants. The gastric bypass group had a peak alcohol breath level of 0.08%, while the control group had a level of 0.05%. The gastric bypass group needed an average of 108 minutes to reach an alcohol breath level of 0, while the control group reached this level after an average of 72 minutes. Hagedorn et al stated that these findings provide evidence that health care providers should encourage patients who have undergone gastric bypass to exercise caution with alcohol consumption.

Klockoff et al⁴² reported patient complaints of increased sensitivity to alcohol after gastric bypass surgery. Twenty-four women were studied for blood alcohol levels. Twelve women who had undergone gastric bypass were in the experimental group and 12 women who had not undergone gastric bypass were in the control group. All women were of similar weight, age, and health status. After ingestion of alcohol, the median time to peak blood alcohol level was 10 minutes in the bypass patients, compared to 30 minutes for the control group. At 10 and 20 minutes post-dosing, the bypass group had significantly higher blood alcohol levels. Klockoff et al⁴³ hypothesized that patients were considering their alcohol tolerance based upon what they had been able to consume at a heavier weight. It has been suggested that “drugs of abuse compete with food for brain reward sites. Overeating and obesity may act as protective factors reducing drug reward and addiction.”^43p105

The risks generally associated with RYGBP differ in incidence between the open and laparoscopic approaches. Notably, the incidence of ventral hernia and wound infections are much higher in the open approach. The incidence of perioperative mortality associated with the procedure has commonly been reported as approximately 0.5%.¹⁶ Data on this, however, have been variable, and more recent unpublished data from the ASMBS suggest that mortality may be substantially less.¹⁶ Even with a 0.5% mortality rate, RYGBP compares favorably with most other major abdominal surgical procedures in terms of safety, particularly considering the risks inherent with this patient population.¹³, ¹⁶, ¹⁹, ³⁵

The risks associated with the laparoscopic adjustable gastric band in general are less when they do occur and often are dealt with relatively easily with another procedure (eg, revising the abdominal wall port).¹³, ⁴⁰ The long-term incidence of risks of the laparoscopic adjustable gastric band remains unknown. These risks will be better defined as surgeons' experience with the procedure increases; as with any bariatric procedure, the surgical risks need to be compared to the risks of remaining morbidly obese.¹³, ¹⁶, ¹⁹, ³⁵

Of patients who have undergone weight-loss surgery, 12% to 20% require follow-up surgeries to correct complications, the most common of which is hernia repair.⁴⁴ Some patients develop gallstones after weight-loss surgery. This can largely be prevented by the patient taking supplemental bile salts for the first six months after surgery. Additionally, concomitant cholecystectomy at the time of RYGBP can be considered for patients with known cholelithiasis. Many patients develop nutritional deficiencies, such as anemia, osteoporosis, and metabolic bone disease. These deficiencies usually can be avoided with multivitamin replacement and monitoring of serum vitamin and mineral levels.

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Patient Selection 

Criteria for surgery are based primarily on the original National Institutes of Health (NIH) consensus panel criteria.⁴⁵ The patient must

Other factors considered include the patient's

Contraindications for bariatric surgery include active substance abuse other than food, certain psychiatric disorders, and previously demonstrated noncompliance with medical and psychiatric care.⁴⁰ Indicators of poor outcome include a chaotic lifestyle, lack of commitment, inability to care for oneself, lack of motivation, lack of social support, poor insight or judgment, and social isolation.⁴⁰

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Initial Evaluation and Preoperative Preparation 

Generally, patients presenting for bariatric surgery are very informed and often self-referred. The initial evaluation by the surgeon or the bariatric clinician generally is a one- to two-hour clinic visit during which the clinician obtains an extensive patient and weight history. Weight history includes

Furthermore, the clinician may ask the patient to use an established scale to rate

The bariatric clinician also documents the patient's current weight, height, BMI, waist and hip circumferences, vital signs, medical-surgical review, prior hospitalizations, medications being taken including antidepressants, and presence of medication and environmental allergies. The clinician reviews with the patient the types of bariatric procedures offered and the relative benefits and risks of each. Patients are required to complete a thorough preoperative workup, including:

The patient also receives instructions regarding

Internal medicine clearance 

Depending on the patient's health status and history, certain tests may be needed, such as a complete blood count, chemical profile, thyroid test, lipid profile, urinalysis, and electrocardiogram. Patients with diabetes should have their glycosylated hemoglobin (ie, HgB A1C) measured to evaluate glycemic control and the need for specific interventions. Additional testing requirements may be ordered as clinically indicated, such as a

After surgery is scheduled, the patient will be evaluated by an anesthesiologist. The patient also is required to attend a hospital support group meeting. The hospital support meetings allow prospective or postoperative patients to interact and receive support from more experienced patients, many of whom are familiar with the nuances of the impact that bariatric surgery can have on a patient's life.

Psychiatric evaluation 

Most morbidly obese patients have normal psychological functioning. A significant minority, however, have problems such as severe depression, binge eating, trauma, and other emotional problems that need preoperative intervention.⁴⁶ All patients, therefore, require evaluation by a psychiatrist or psychologist for preoperative clearance. The psychiatric clinician assesses many pertinent psychological factors such as whether the patient has realistic goals for surgery and is committed to the lifelong medical follow-up that is required after bariatric surgery. The psychiatric clinician assesses many other factors including the patient's

Insurance preauthorization 

Obesity is a nationwide problem with associated astronomical financial impact. Patients who are obese require care and medical insurance to deal with weight loss. Although bariatric surgery costs range from $20,000 to $35,000 and possibly more, the resulting weight loss reduces health care and medication costs from obesity-related comorbidities. The patient must be proactive in contacting the insurance company to establish whether bariatric surgery is a covered benefit. Although administrative support often is available from bariatric clinic staff members, patient involvement with the insurance preauthorization process is imperative to the success in getting a proposed procedure approved.

Preoperative expectations of the patient 

Although the bariatric clinician provides the patient with extensive patient education literature regarding bariatric surgical options, the clinician also encourages the patient to seek out other resources to learn more about bariatric surgery. This helps the patient approach the surgery with unbiased information and expectations that are as realistic as possible. These resources include:

Nutritional instructions 

All programs provide preoperative nutritional counseling with a specific focus on the postoperative diet regimen that the patient will undergo. During the counseling, the nutritionist instructs the patient about the specific diet and offers suggestions and support for compliance.

Some surgeons also require patients to lose weight before the bariatric surgical procedure. The rationale for this is to reduce the adverse effects of comorbid conditions, improve the ability of the patient to undergo the surgical procedure, and help ensure patient compliance. With such an approach, the surgeon assigns a set number of pounds that the patient must lose before surgery.

Recently, some insurance carriers have begun requiring monthly weight-loss counseling for a set period of time before payment for bariatric surgery is approved. The data evaluating such an approach, however, have shown minimal benefit in terms of patient outcomes.⁴⁷

A preoperative liquid diet has been shown to decrease liver volume in bariatric surgical patients, which can facilitate exposure of the stomach during the surgical procedure.⁴⁸ As a result, some surgeons now require a patient to maintain a liquid diet for two weeks before the procedure rather than requiring certain degrees of weight loss. Patients obtain high protein liquids from health food stores or pharmacies and try them preoperatively for their postoperative diet.

Smoking cessation 

The primary care physician or bariatric clinician advises the patient not to smoke for six to eight weeks before the procedure to minimize perioperative risks. Use of nicotine replacements or bupropion may help to minimize weight gain with smoking cessation. The clinician advises the patient that people who smoke experience delayed healing and recovery. Smoking also is associated with an increased risk of respiratory complications and postoperative wound infections in ambulatory surgery patients.⁴⁹ Furthermore, patients who smoke have a greater risk for cardiac problems when undergoing general anesthesia.⁵⁰ In one study,

Patients under age 65 without symptoms of ischemic heart disease who smoked shortly before surgery had more [markers of restricted blood flow to the heart] than nonsmokers, prior smokers, or chronic smokers who did not smoke before surgery.^50(p856)

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Preoperative Nursing Assessment of the Bariatric Patient 

When the patient arrives at the preoperative area, the preoperative nurse instructs the patient to change into a hospital gown. After reviewing the patient's medical record and history, the preoperative nurse starts an IV. The circulating nurse arrives in the preoperative area and greets the patient and any family members present. The circulating nurse has the patient verify his or her identity and proposed procedures and cross checks that information with the patient's identification bracelet and medical record and the OR schedule. After reviewing the preoperative nurse's assessment, the circulating nurse assesses the patient, particularly focusing on any preexisting comorbid conditions and factors that will affect positioning and perioperative care, such as the ability to lie flat without compromising respiratory status. The nurse also assesses and documents the patient's

The circulating nurse identifies and reports to the surgeon and anesthesiologist any indecisiveness, change of mind, or feelings of doom by the patient or lack of family member support for the patient. The nurse also asks the patient whether he or she uses a continuous positive airway pressure (CPAP) machine at home for sleep apnea. If so, the nurse determines whether the patient brought the CPAP machine to the hospital for postoperative use and if not, ensures that the postanesthesia care unit (PACU) nurse is aware that the patient will need CPAP postoperatively.

The circulating nurse performs a physical assessment particularly examining the patient's skin integrity and documents any areas of existing skin breakdown particularly between skin folds. The circulating nurse then determines whether any additional test results are present in the patient record, such as

The circulating nurse reviews the planned procedure with the patient, allowing opportunities for the patient and family members to ask questions and express their needs.

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Anesthesia Care of the Bariatric Patient 

The anesthesiologist performs an anesthetic preoperative evaluation focusing on the medical consequences of the patient's morbid obesity. This is accomplished by evaluating the symptoms of each organ system, paying particular interest to the patient's cardiovascular and respiratory status. Additional testing and evaluation is performed based on the patient's individual history and current function. If warranted, the anesthesiologist orders specific interventions to better prepare the patient for surgery. The anesthesiologist explores the patient's previous anesthetic history and requests previous medical records if available. The anesthesiologist also focuses on anesthetic problems experienced by genetic relatives.

Medication absorption concerns 

Fat tissue delays medication absorption and later stores medications; therefore, it may take more anesthetic medications to attain and maintain the proper level of anesthesia, which increases the risk of anesthetic complications. The use of intramuscular injections should be avoided because intramuscular injections may be administered into fatty tissue rather than muscle. This causes a highly varied rate of medication absorption.

Cardiovascular and respiratory concerns 

Morbid obesity taxes many organ systems, particularly the cardiopulmonary system, forcing the patient's body to do more with less. Morbidly obese patients demonstrate increased cardiac afterload, decreased oxygen supply, and increased risk of coronary artery disease, all of which can lead to left ventricular hypertrophy.⁵² In morbidly obese patients, right ventricular failure can be caused by chronic hypoxemia, hypercarbia, polycythemia, and pulmonary hypertension, leading to a condition known as Pickwickian syndrome (ie, alveolar hypoventilation, hypersomnia, and obesity).⁵³ The respiratory system of the morbidly obese patient is disadvantaged by overall increased fat metabolism.⁵⁴ Elevated oxygen consumption and carbon dioxide (CO₂) production necessitate increased minute ventilation. Furthermore, the chest wall mechanics of morbidly obese patients are heavily burdened by the additional weight, which must be moved with each breath.

Aspiration risk 

A morbidly obese patient is at increased risk of aspiration and increased risk of significant damage if aspiration occurs.⁵⁴ Typically, fasting gastric volumes are greater than 25 mL with a pH greater than 2.5, which if aspirated is sufficient to cause significant lung parenchymal damage. Increased gastric pressure, which exaggerates the risk of aspiration, is present from the enlarged abdominal wall mass, increasing the overall abdominal pressure of the obese patient. The risk is worsened by the presence of a hiatal hernia and the degree of gastroparesis, which commonly is elevated in the obese diabetic patient.⁵⁵

Airway challenges 

Of all conditions known to be associated with morbid obesity, failed intubation carries one of the gravest risks when a patient is undergoing general anesthesia. A morbidly obese patient with significant obstructive sleep apnea is further disadvantaged by having a low chance of successful mask ventilation. In general, morbidly obese patients are prone to respiratory problems because of reduced oxygen reserves and high rates of oxygen consumption. Thus, the time from induction to intubation needs to be minimized because the rate of oxygen desaturation is fast. Vocal cord visualization also is more difficult with an obese patient. Lack of cervical neck mobility often is present with partial airway obstruction because of fatty pads in the oral pharynx. The anesthesiologist, therefore, may need to secure the patient's airway by performing either an awake intubation or rapid sequence induction with cricoid pressure. Preinduction preparation typically involves paying particular attention to patient positioning and providing extended preoxygenation to maximize oxygen reserves. The anesthesiologist ensures that supplies and equipment for additional interventions are readily available because time taken during induction for contingency planning is costly. Additional equipment might include an intubating-laryngeal mask airway and a fiberoptic bronchoscope.

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Intraoperative Nursing Care of the Bariatric Patient 

Before the patient is transferred from the preoperative area to the OR, the circulating nurse and scrub person prepare the OR for the patient's specific surgery, taking into consideration the individual needs of an obese patient. For instance, the patient's weight and type of fat distribution (ie, android, gynoid) affect patient positioning and required equipment and instrumentation. The circulating nurse assists the anesthesiologist during intubation and provides assistance if the patient experiences distress after moving to the OR bed and lying flat. The circulating nurse remains vigilant for changes in the patient's cardiac, respiratory, and vital sign status throughout the procedure.

Respiratory system 

Obese patients often have little respiratory reserve and can become distressed quickly and easily. Obese patients also may be short of breath as a result of increased metabolic needs.⁵⁶, ⁵⁷ Often, an obese patient also has asthma or sleep apnea that requires the use of a CPAP machine at home.

Interventions 

Respiratory reserves are limited, so careful preparation is essential to ensure safe induction. After having determined during the preoperative assessment whether the patient is able to tolerate lying flat without experiencing a sense of asphyxiation or suffering from gastric reflux, the circulating nurse and anesthesiologist prepare the OR bed with padding to elevate the head of the bed. The goal is to have the patient lie as flat as is tolerable to assist the anesthesiologist with airway management and intubation. The team avoids placing the patient in the Trendelenburg position if possible, at least until after intubation.

The circulating nurse obtains the difficult airway cart for immediate availability if needed and assists the anesthesiologist with obtaining respiratory supplies as well as a tracheostomy kit. It may be necessary for the circulating nurse to obtain respiratory medication inhalers from the pharmacy or to ensure that the patient's own inhalers are brought into the OR with the patient. While assisting the anesthesiologist during induction of anesthesia, the circulating nurse is prepared to provide cricoid pressure to facilitate intubation and help prevent gastric reflux and aspiration. The circulating nurse helps the anesthesiologist ensure that all of these supplies, the equipment, and medications are kept available during the entire procedure because the patient may experience problems during extubation.

Cardiac system 

An obese patient is prone to cardiac disease as a result of hypertension, diabetes, and increased lipids. An obese patient also may have little cardiac reserve and can become distressed quickly and easily. Compression of the abdomen on the vena cava and aorta may impede circulation of oxygenated blood. An obese patient may suffer from

The patient also may have had myocardial infarction in the past.

Interventions 

After having determined the patient's “normal” cardiac status and the patient's preoperative hematocrit during the preoperative assessment, the circulating nurse ensures that all emergency supplies and the crash cart are available. Although blood is almost never ordered or needed, some surgeons order a type and screen, which helps the circulating nurse react quickly if an emergency occurs.

Vascular system 

Obese patients have an increased incidence of deep vein thrombosis (DVT).¹⁶ A tourniquet effect caused by thromboembolic disease (TED) hose and sequential compression device (SCD) leggings or twisted gowns or linen can impede blood flow and cause nerve or skin damage. Patients' veins or other anatomical areas often are difficult to access because of the excess weight, and health care providers may have difficulty identifying essential landmarks.

Interventions 

When it is necessary to administer subcutaneous medications, the anesthesiologist and circulating nurse choose sites other than the abdomen. To prevent DVT, the circulating nurse applies SCD leggings and ensures that the unit is activated before induction of anesthesia. Properly fitting, full-length leggings are optimal, but knee-high leggings may be indicated to obtain a proper fit. Least desirable are the foot compression devices because they are less effective; therefore, the circulating nurse should document the reason for using the foot compression devices on the intraoperative nursing record. The circulating nurse ensures that the patient's clothing, bed linens, and SCD leggings are not binding or constricting, which can cause a tourniquet effect.

Musculoskeletal and nervous systems 

Obese patients are more prone to problems with positioning and positioning injuries during surgery because of the strain that excessive weight places on their musculoskeletal and nervous system structures. Ensuring availability of appropriately sized supplies and equipment also can be challenging. The standard supine position facilitates access to the surgical field but the patient's intestines and omentum may obstruct the view of the intra-abdominal surgical site. To compensate for this and to facilitate visualization of the surgical field, the surgeon may request that the patient be placed in the steep, reverse Trendelenburg position with lateral tilting of the OR bed to shift the intestines and omentum toward the patient's feet.

Some OR beds have a walk feature. When activated the bed will roll; staff members guide the direction of the bed movement. This is helpful when moving the bed from room to room. The walk feature should never be activated with a patient on the bed because loss of control can easily occur, injuring the patient or staff members. The foot props prevent the patient from sliding, thus preventing shearing skin injuries, but the anesthetized patient's knees and ankles can bend and dislocate in this position. The weight of the patient's legs also can cause the knees or ankles to dislocate and possibly cause injury to the popliteal blood vessels. The safety strap may cause cutaneous lateral femoral cutaneous nerve damage. Finally, the patient can become trapped under equipment if the surgical position is changed intraoperatively.

Interventions 

Before the patient is brought to the OR, the circulating nurse determines whether the patient is a candidate for a postoperative bariatric bed, which enables the patient to move side-to-side postoperatively, facilitates comfort, and assists nurses in providing postoperative patient care. The circulating nurse determines whether the patient should have a bariatric bed postoperatively and orders it before surgery to ensure that it arrives at the OR before the surgical procedure is completed. Patients who weigh more than 300 lbs are candidates for using this type of bed. The bed also is recommended for patients who have a great deal of difficulty moving preoperatively.

The circulating nurse selects an appropriate OR bed based on the patient's weight and height and the surgeon's preference for surgical positioning. The circulating nurse considers the manufacturer's recommendations for weight limitations to prevent tipping or malfunctioning. The selected OR bed must be able to function in the steep reverse Trendelenburg position and must be able to tilt laterally from side-to-side. These positions are used during bariatric procedures to shift the patient's abdominal contents toward the feet, away from the surgical site. Perioperative staff members ensure that the OR bed remains plugged in to an electrical outlet even when it is not in use to maintain the full battery charge. The circulating nurse checks the mattresses on the OR bed to ensure their integrity is intact and ensures availability of special equipment and appropriate padding materials to prevent muscle, bone, nerve, and skin injuries when securing the patient and his or her extremities.

The surgical team helps the patient transfer onto the bed and ensures that the patient's weight is evenly distributed over the center of the OR bed. All perioperative team members work cooperatively to prevent the patient from sliding on the OR bed, which could result in shearing skin injuries, when positioning the patient and during surgery.

The circulating nurse removes any blankets or positioning devices from the patient's upper torso after the anesthesiologist has intubated the patient and secured the airway. The circulating nurse ensures that the patient's feet are snug against the padding of the foot props and the legs, knees, and ankles are in proper body alignment. The circulating nurse applies the safety strap across the patient's upper thighs and places tape over a sheet across the patient's lower extremities to maintain this position. The circulating nurse ensures that all of the patient's pressure points are well padded and supported. The circulating nurse secures the patient's arms on well-padded arm boards, avoiding strain on the limbs and ensuring less than 85-degree abduction from the OR bed. Before applying the surgical drapes, the anesthesiologist places the bed in the steep reverse Trendelenburg position and tilts the bed according to the surgeon's preference to check for potential problems.

The circulating nurse, anesthesiologist, and surgeon assess the patient's position and identify needed corrections before proceeding with the surgical procedure. All staff members continue to assess the patient's position throughout the procedure, particularly if the position of the OR bed or equipment is changed, and immediately correct any problems that arise.

Gastrointestinal and urinary systems 

Obese patients are prone to gastroesophageal reflux disease. Furthermore, abdominal pressure increases the risk of vomiting and aspiration pneumonia. The pneumoperitoneum may be responsible for transient oliguria during surgery resulting from pressure on the renal cortex and inferior vena cava. Therefore, fluid management during surgery on the obese patient can be difficult.

Interventions 

The anesthesiologist ensures that the patient received histamine H2 antagonist preoperatively if indicated to decrease gastric pH and gastric fluids. To help decrease abdominal pressure, the circulating nurse ensures that the pneumoperitoneal equipment is functioning correctly and that the anesthesiologist has a variety of nasogastric tubes available. The surgeon and circulating nurse should monitor the patient pressure readings carefully and agree on the maximum patient pressure settings. The pneumoperitoneum increases systemic vascular resistance, decreases cardiac index, and transiently increases mean arterial pressure. The anesthesiologist, therefore, may request that the patient pressure be lowered or the CO₂ be turned off temporarily to stabilize the patient's vital signs.

If an indwelling urinary catheter is required, three staff members may be needed for its insertion. The circulating nurse ensures that care is exercised when moving the patient's extremities. Two staff members should move the legs in unison and support the knees in a frog-leg position and provide labial retraction while the circulating nurse preps the perineal area and inserts the catheter. It is important, therefore, that the urinary catheter be properly placed, functional, and positioned to prevent kinking so that the anesthesiologist can monitor and manage the patient's intake and output.

Psychosocial system 

The surgeon and anesthesiologist may minimize preoperative medications so that the patient can participate better in moving from the preoperative stretcher to the OR bed and in positioning if the patient is undergoing an epidural anesthetic. Decreased use of medication (eg, anxiolytics), however, may increase the patient's level of anxiety. Having improperly sized equipment may embarrass the patient and decrease the patient's confidence in the health care provider's ability to provide safe patient care.

Interventions 

The circulating nurse ensures that properly sized equipment and supplies are available before the patient is transferred into the OR. The circulating nurse should remain with the patient when he or she is brought into the OR, particularly ensuring safe patient transfer and facilitating patient comfort and warmth.

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Preventing Potential Complications 

Numerous complications are possible during bariatric surgery. Some of these complications include hypothermia, intra-abdominal injury or anastomosis leakage, retained foreign bodies, postoperative infection, and anesthetic emergence complications.

Hypothermia 

Hypothermia increases metabolic demand, oxygen demand, and cardiac workload. An upper-body temperature-regulating blanket warms a patient's core better than a lower-body blanket. Instruments also fall off the field more easily when a lower-body blanket is in place. Both an upper- and lower-body blanket, however, may be indicated at times.

Interventions 

The circulating nurse ensures that the OR is warm and that the patient remains covered until surgery is underway. The circulating nurse applies an upper-body temperature-regulating blanket, lower-body blanket, or both, depending on the surgical site. After anesthesia is induced and the patient is prepped and draped, the circulating nurse may turn down the room temperature. The circulating nurse documents the patient's intraoperative temperature as monitored by the anesthesiologist. At the conclusion of surgery, the circulating nurse increases the room temperature and then applies warm blankets after the patient has been transferred onto the transport stretcher.

Intra-abdominal injury or anastomosis leakage 

The anastomosis may leak postoperatively. Malfunctioning supplies or equipment can result in surgical complications and failure of the anastomosis.

An adjustable gastric band can rupture if it is overinflated. For the 10-cm band, the maximum volume of saline is 4 mL. For the 11-cm band, the maximum volume of saline is 12 mL.

Interventions 

The circulating nurse must ensure that the CO₂ insufflation device is adjusted to the proper settings for establishing the pneumoperitoneum and document the initial settings and pressures and any changes made during the procedure. The circulating nurse locates and assembles the gastroscope endoscopy equipment to check for patency of the gastrojejunal anastomosis during the surgical procedure. The circulating nurse also ensures that the anesthesiologist has additional 18-Fr nasogastric tubes; smaller tubes usually coil in the patient's esophagus because of excess nasopharyngeal tissue.

If the surgeon performs an intraoperative dye test, the circulating nurse mixes 1 mL of methylene blue in a sponge bowl with approximately 200 mL of saline. The circulating nurse provides the anesthesiologist with the sponge bowl of diluted methylene solution, a disposable underpad, a 60-mL catheter-tip syringe, and a Kelly clamp. The surgeon instructs the anesthesiologist when to inject a specified quantity of the dye solution into the nasogastric tube. The anesthesiologist then occludes the accessory port (ie, blue tubing) on the nasogastric tube with the Kelly clamp. The presence of blue in the stomach fluid indicates a leak at the anastomosis site. Alternatively, the surgeon may fill the gastric area with fluid and then have the anesthesiologist inject the nasogastric tube with air. The presence of air bubbles in the fluid indicates a leak at the anastomosis site.

To ensure patient safety, the circulating nurse adheres to the FDA regulations for safe medical device tracking. The circulating nurse records implant information on the implant record section of the perioperative record, including

If a piece of equipment or a supply malfunctions, the circulating nurse should report it to the charge nurse, complete the malfunction form, and ensure that the device and its packaging are kept with the appropriate paperwork.

Retained foreign body 

Studies have shown that obese patients are at higher risk for a retained foreign body.⁵⁸, ⁵⁹ Increased abdominal cavity size, large abdominal panus, and increased omental fat may account for this increased risk.

Interventions 

The circulating nurse ensures that all counts are performed according to facility policy for counting sponges, sharps, instruments, and accessories. Furthermore, the scrub person and circulating nurse ensure that any item inserted into the abdomen is counted carefully, documented on the count sheet, and communicated in reports to other staff members.

Postoperative infection 

Perspiration and friction between fat folds may cause the skin to breakdown, so obese patients are particularly prone to this problem. Decreased mobility creates additional risk for skin breakdown throughout the perioperative and recovery periods.

Interventions 

The circulating nurse ensures that antibiotics were administered in a timely fashion as ordered before surgery and provides the anesthesiologist with additional doses if needed for redosing during surgery. When the circulating nurse is performing the surgical skin prep, additional staff members may be required to retract the skin folds for thorough cleansing and drying.

Anesthetic emergence complications 

An obese patient can desaturate his or her oxygen levels quickly, particularly because this patient population has very little cardiopulmonary reserve. The patient may wake slowly or resedate as medications stored in the fatty tissues are metabolized. The patient may not be able to support his or her own airway immediately because of excess nasopharyngeal tissue. Every effort must be made to prevent vomiting because vomiting can injure the anastomosis.

Interventions 

The circulating nurse provides needed assistance to the anesthesiologist, such as ensuring availability of medications (eg, ondansetron, metclopramide, ketorolac) that may be needed during emergence from anesthesia or during the immediate postoperative recovery period. The circulating nurse remains with the patient during emergence from anesthesia and assists the anesthesiologist in preventing and treating postoperative nausea, vomiting, and pain.

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Preparing for Transfer to the PACU 

At the end of the procedure, the circulating nurse evaluates and documents the patient's status, including skin condition (eg, skin folds, pressure points such as the sacral area). Documentation is important to provide an accurate picture of the perioperative care administered and the outcomes of the care provided. The circulating nurse documents all intraoperative care provided, including

The circulating nurse contacts the PACU nurse before transferring the patient to the PACU to communicate any postoperative patient care needs (eg, whether extra-large equipment such as blood pressure cuffs may be needed; whether CPAP is needed, and if so, its location; any other respiratory needs). The circulating nurse also notifies the PACU nurse whether the patient will arrive in a bariatric bed.

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The PACU Phase 

Postoperative recovery may be particularly difficult for an obese patient and requires that the patient be prepared and able to participate in the process as much as possible. On arrival in the PACU, in addition to the standard hand-off report, the circulating nurse reports to the PACU nurse the patient's weight and BMI and the degree of elevation of the head of the bed that the patient requires to breathe easily.

A key component of the patient's PACU stay is airway management. The PACU nurse ensures that the head of the bed is elevated adequately, the patient's pulse oximetry is monitored closely, and that supplementary oxygen is administered according to the surgeon's and anesthesiologist's orders.

To manage pain while in the PACU, patients typically are started on patient-controlled analgesia (PCA), although the PACU nurse may augment the PCA with administration of IV narcotics as needed. The PACU nurse begins the patient on the progressive diet by encouraging the patient to drink 2 oz of water every hour.

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Medical-Surgical Unit Care 

After the patient has been transferred from the PACU to the postoperative medical-surgical unit, health care providers follow established clinical guidelines to ensure early recognition and management of potential complications associated with bariatric surgery. Comorbid conditions often make recognition of postoperative complications in bariatric patients difficult. The guidelines address the most common variances found in the postoperative bariatric patient, such as fever, tachycardia, hypoxia, and hypotension.

To be eligible for discharge, the patient must meet specific discharge criteria. The patient must be able to tolerate clear liquids and must be able to drink three liquid meal replacement drinks per day (ie, drinking each 8 oz serving slowly over one hour) without experiencing nausea or vomiting. The patient must also be able to ambulate independently around the nursing unit and must be able to void without difficulty.

When the patient has achieved these discharge criteria, the health care team (eg, nurse, dietician, surgeon) provides the patient with oral and written postoperative discharge instructions. These instructions include a discussion of pain management interventions (eg, liquid narcotics when the patient is tolerating oral fluids) and the symptoms that require medical consultation, such as

Bariatric surgery patients are discharged with very specific dietary instructions. Dietary progression consists of consuming full liquid meals for two weeks. After that, the patient progresses to soft solids, and then gradually progresses to a complete regular diet. The amount that the patient can consume progresses from 2 oz of water per hour on day one to low-fat solids after four months.

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Long-Term Postoperative Care 

Although a detailed discussion of the postoperative concerns and lifelong follow-up is beyond the scope of this article, several of the issues that affect bariatric surgery patients warrant mention. Postoperatively, the bariatric patient should endeavor to obtain medical care from multidisciplinary bariatric-trained health care providers. It is very important for the patient to inform all future health care providers, particularly those not involved in bariatric surgery, about the type of bariatric procedure that was performed. Lifelong medical surveillance after bariatric surgery is a necessity. Weight-loss surgery follow-up should include:

Postoperative medication instructions 

The patient is instructed that medications, unless very small in size, should be crushed or taken as a liquid, a chewable pill, or a capsule that can be opened and mixed with yogurt or applesauce. This helps to prevent pills from becoming stuck in the gastric pouch or gastric opening and facilitates absorption of the medications. Medications that require therapeutic-level monitoring (eg, warfarin sodium, phenytoin, evothyroxine sodium) should be monitored more frequently after malabsorptive procedures to ensure the proper levels. The patient is instructed to avoid taking sustained-released (SR) or long-acting (XL) medications because of their potential to not be absorbed after malabsorptive procedures. Medications taken before surgery should not be discontinued right after surgery, especially antidepressants. The patient is instructed to avoid taking NSAIDS permanently if possible. Some patients cannot do so, often because of severe arthritis. For those patients, liquid preparations that will leave the pouch quickly are used and the patient takes a proton pump inhibitor at the same time to help prevent stomach ulcers. Patients are instructed to avoid smoking if at all possible to minimize the chance of gastrointestinal bleeding. Cautious use of diuretics is recommended to decrease the chance of dehydration. If long-term pain management is required, it is recommended that medication be delivered through a dermal patch.

Postoperative diet 

The patient is instructed to

Health care providers review and reeducate the patient on each dietary stage and remind the patient to assess for hair loss. The patient is instructed to maximize protein intake and take supplements like biotin. Some patients also have reported good results with minoxidil. The patient is instructed to avoid drinking alcoholic beverages because the enzyme that metabolizes alcohol is in the duodenum, which is bypassed in bariatric surgery. The patient is reminded that carbonated drinks can be irritating and should be avoided.

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Outcomes 

Perioperative facility managers should identify and monitor outcome indicators for bariatric surgery patients. Staff members should be knowledgeable about the indicators, and the results of monitoring should be made available to all staff members as part of the performance improvement process. Suggested criteria to monitor include:

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Pregnancy After Bariatric Surgery 

An example of the tremendous effect of bariatric surgery on a patient's life is pregnancy. Many patients having bariatric surgery are of childbearing age. Obesity has a negative effect on a woman's reproductive abilities. Obesity causes a decrease in the sex hormone-binding globulin (SHBG), which acts as a plasma transport protein, binding strongly with testosterone and weakly with estradiol. Therefore, circulating androgens increase, which converts the estrogen into adipose tissue. This process causes many reproductive problems, but after weight loss, the SHBG returns to normal and fertility and ovulatory menstrual cycles improve. Women who have experienced weight loss may feel more attractive, which may increase sexual activity. Thus, the woman may find herself unexpectedly pregnant.⁵¹

Typically, the initial postoperative adjustment phase is one-and-a-half to two years; a female bariatric patient should avoid pregnancy during this time. Nutritional deficiencies can occur, especially with vitamin B₁₂, iron, vitamin D, and calcium, so it is difficult to meet the nutritional needs of the fetus during the first trimester of pregnancy, particularly if the woman suffers from nausea and vomiting.

Female patients are instructed to use two methods of birth control. Oral contraceptives may not be reliable with the patient's altered absorption status. A diaphragm will require several fitting changes during the weight loss.⁵¹ Ideally, the patient should undergo a preconception nutritional analysis and the patient should be monitored throughout her pregnancy for the onset of gestational diabetes. After giving birth, the woman should be advised that breastfed babies of mothers who have undergone bariatric surgery are at risk for nutritional deficiencies, such as megaloblastic anemia.⁵¹

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Conclusion 

Many bariatric surgeons report that postoperative bariatric patients are among the most appreciative and happy. Bariatric surgery helps these patients achieve enjoyment and improvement in their lifestyle and their quality of life. Although these patients often return to health care facilities for additional needed care and procedures, possibly for a lifetime, many verbalize a very high satisfaction rate as a result of their bariatric surgery.

A study regarding the quality of life after bariatric surgery was conducted by Hager⁶⁰ three months after patients had undergone gastric bypass surgery. The Impact of Weight on Quality of Life-Lite (ie, IWQOL-Lite) instrument, which is specific for obesity, was used to measure five areas of life:

The survey results identified marked improvements in the patient's overall quality of life and physical functioning, as well as the patient's ability to decrease or discontinue medications related to comorbid conditions.

Hager noted that some postoperative patients experienced “buyer's remorse” in that they felt and looked worse than they did before surgery. As recovery progressed and the patients experienced health improvement and desired lifestyle changes, however, most patients expressed satisfaction with their decision.⁶⁰ According to Hager, gastric bypass patients reported that their perceptions and the distress they felt when in public rated a high of 80%, but that it decreased postoperatively to less than 20%.⁶⁰ The major limitation with Hager's study is the small sample size and study duration. Only 12 of the 73 patients involved in the study returned their survey and the study duration was only four months.⁶⁰

Care of patients undergoing weight-loss surgery is an area with almost endless research opportunities. The field is growing rapidly so more information is needed to support and guide changes in current standards of practice. Many of the current bariatric procedures have only been performed in the United States for a short time, so long-term patient outcomes still need to be evaluated and documented.

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Examination 

Perioperative Nursing Care of the Bariatric Surgical Patient 

Purpose/Goal 

To educate perioperative nurses about caring for an obese patient undergoing one of the common bariatric surgical procedures.

Behavioral Objectives 

After reading and studying the article on perioperative nursing care of patients undergoing bariatric surgery, nurses will be able to

Questions 

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Answer Sheet 

Perioperative Nursing Care of the Bariatric Surgical Patient 

Event #08042

Session #1309

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Learner Evaluation 

Perioperative Nursing Care of the Bariatric Surgical Patient 

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This evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate these items on a scale of 1 to 5.

Purpose/Goal 

To educate perioperative nurses about caring for an obese patient undergoing one of the common bariatric surgical procedures.

Objectives 

To what extent were the following objectives of this continuing education program achieved?

Content 

To what extent

Test Questions/Answers 

To what extent

Learner Input 

What other topics would you like to see addressed in a future continuing education article? Would you be interested or do you know someone who would be interested in writing an article on this topic?

Topic(s):___________________________________________________________________________________________________________________

Author names and addresses:__________________________________________________________________________________________________________________

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References 

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8. Buchwald H , Avidor Y , Braunwald E , et al.   Bariatric surgery: a systematic review and meta-analysis . JAMA . 2004;292(14):1724–1737
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9. Bariatrics . In: Stedman's Medical Dictionary . 28th ed.. Philadelphia, PA: Lippincott Williams & Wilkins; 2006;p. 203
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11. Santry HP , Gillen DL , Lauderdale DS . Trends in bariatric surgical procedures . JAMA . 2005;294(15):1909–1917
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12. CMS Manual System. Pub 100-03. Medicare National Coverage Decisions. Transmittal 54. Bariatric surgery for treatment of morbid obesity. Centers for Medicare & Medicaid Services. http://www.cms.hhs.gov/Transmittals/Downloads/R54NCD.pdf. Accessed May 29, 2008.
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13. Graling P , Elariny H . Perioperative care of the patient with morbid obesity . AORN J . 2003;77(4):802–824
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14. Maggard MA , Shugarman LR , Suttorp M , et al.   Meta-analysis: surgical treatment of obesity . Ann Int Med . 2005;142(7):547–559
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15. Commonwealth of Massachusetts Board of Registration of Medicine. Medical Board Patient Care Assessment Committee. Postoperative management of weight loss surgery patients. Boston, MA: January 2005.
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