Bariatric Surgery: A Guide for Mental Health Professionals

Bariatric Surgery
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Green reported that she has been overweight since early adulthood.

Ten top tips for the management of patients post-bariatric surgery in primary care

She is currently below her highest adult weight of lbs. She reported losing approximately 25 lbs. Green reported her mother is and father was obese. Her two siblings are of average weight. Her medical history and current medications are known to you. Of note, she reported a history of heart disease and hypertension. Green reported eating two to three meals and several snacks each day. She reported eating large portion sizes of calorically dense foods at many of her meals.

Currently, Ms. She denied any behaviors consistent with binge eating disorder. She denied any compensatory or purging behaviors. Unfortunately, she has been unable to maintain these losses over long periods of time. She reported a moderate level of physical activity at present, walking several times each week. In summary, Ms. Green's reported eating calorically dense foods and large portions sizes, both of which are likely contributors to her obesity. Green denied any psychiatric treatment history.

She denied any symptoms of depression upon questioning. She revealed that her father was an alcoholic but denied any alcohol problems herself. She also revealed a history of physical abuse from past boyfriends. Upon questioning, she denied involvement in a physically abusive relationship at present.

She reported no suicidal ideation. No evidence of a thought disorder was found. Green reported no significant life stressors at this time. This appears to be an excellent time to have surgery. Green appears to be an appropriate candidate for bariatric surgery. Weight loss following surgery will likely decrease her risk of weight related health problems in the future and improve her quality of life. I met today with Ms. Alice Smith whom you referred for a behavioral assessment of her appropriateness for bariatric surgery. She is married and lives with her husband and three of her four adult children.

She has been employed as a telephone operator for the past 24 years. Smith reported that she first recognized being overweight during childhood. She is currently at her highest adult weight of lbs.


She reported a weight increase of 40 lbs. Smith reported her mother and father were average weight. Of note, she reported a history of hypertension and sleep apnea. Smith's early onset of overweight provides evidence for a moderate biological predisposition to obesity. Smith reported eating two meals and several snacks each day. She reported that she typically skips breakfast and eats a very large lunch. For example, she will often eat two large fast food hamburgers, a large order of French fries, a large regular soda, and serving of ice cream.

She reported eating similarly large portion sizes for dinner. During these episodes, she reported eating without hunger and past the feeling of fullness. She also reported feelings of dysphoria and guilt. Thus, she appears to meet diagnostic criteria for binge eating disorder. She denied any compensatory or purging behaviors following these episodes. She stated that she has not tried to lose weight in the past several years and that she became interested in bariatric surgery after seeing it on television.

Smith reported that she is not physically active at this time secondary to degenerative disc arthritis in her back. Smith's binge eating, regular consumption of calorically dense foods and beverages, and lack of physical activity are likely contributors to her obesity. For the past 5 years, Ms. She indicated that she has experienced a number of significant life stressors over the past few years, including issues related to her oldest son's and her husband's use of alcohol.

She became tearful several times during the assessment. Upon further questioning, she reported difficulty sleeping, decreased appetite, and trouble concentrating. She also reported significant loss of interest in pleasurable activity. Smith reported a number of life stressors at this time. They appear to be impairing her function, as noted above. While Ms. Smith has a BMI above 40, hypertension and sleep apnea, I have concerns about her appropriateness for surgery at this time. As a result, they may interfere with her ability to make the necessary behavioral and dietary changes to ensure a successful postoperative result.

Second, her current diet is quite poor and Ms. Smith reported binge eating several times per week. Third, as compared to our typical surgery candidate, she reported little knowledge of the postoperative behavioral and dietary changes. I made several recommendations to Ms. First, I referred her to our outpatient psychiatry unit for additional assessment and treatment of her depressive symptoms. Second, I encouraged her to attend the Bariatric Surgery Program's monthly support group for the next several months. This will provide her with additional information on the postoperative behavioral and dietary requirements.

I shared these concerns with Ms. Smith and she reported to be in agreement with them. If she is able to address these concerns in the next 3 months, she will likely be a more appropriate candidate for surgery. Volume 14 , Issue S3. If you do not receive an email within 10 minutes, your email address may not be registered, and you may need to create a new Wiley Online Library account. If the address matches an existing account you will receive an email with instructions to retrieve your username. Obesity Volume 14, Issue S3. Free Access.

Thomas A. David B. Tools Request permission Export citation Add to favorites Track citation. Share Give access Share full text access. Share full text access. Please review our Terms and Conditions of Use and check box below to share full-text version of article. Abstract This paper discusses the behavioral evaluation of patients who seek bariatric surgery and the psychosocial complications most frequently observed in these individuals.

Introduction Patients who seek bariatric surgery typically are required to complete a behavioral i.

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Psychosocial Status of Patients with Extreme Obesity Perhaps the principal reason mental health professionals have been included in the preoperative assessment of surgery candidates is the high prevalence of psychiatric and behavioral complications observed in this population. Prejudice and Discrimination Even quality of life scales, however, cannot adequately capture the adverse emotional consequences of the prejudice and discrimination to which extremely obese individuals are daily subjected Predicting Surgical Outcome Based on Psychosocial and Behavioral Status Practitioners have long desired to identify baseline predictors of weight loss and related outcomes Predictors of Outcome To date, there has been limited success in identifying consistent behavioral predictors of outcome after bariatric surgery 4 Clinical Significance of Predictors Thus, at present, there are not adequate data to determine whether the presence of BED, before surgery, is associated with smaller weight loss or other undesirable outcomes.

Behavioral Evaluation Conducted at the University of Pennsylvania All candidates for bariatric surgery at the Hospital of the University of Pennsylvania complete a behavioral evaluation with a mental health professional, all of whom also have expertise in obesity which we believe is critical to conducting a thorough evaluation.

Results have shown no clear-cut predictors of failure. As an example, about 40 percent of candidates for bariatric surgery have a history of depression. This situation almost never presents a problem after surgery.


Solutions Obtaining an objective behavioral sample of eating behavior is a critical component of the presurgical evaluation. Thus, she appears to meet diagnostic criteria for binge eating disorder. Furthermore, without a standardization of practices, the value and purpose of psychological assessment is subject to variation according to each professional or bariatric team Systematic review: an evaluation of major commercial weight loss programs in the Unites States. Role of laparoscopy in revisional procedures Revisional bariatric operations may be performed laparoscopically [] or via open technique [, ]. Some may have maladaptive eating patterns and poor nutritional intake. Diabetes Care 25 2 Abu-Abeid S, Keidar A, Szold A Resolution of chronic medical conditions after laparoscopic adjustable silicone gastric banding for the treatment of morbid obesity in the elderly.

There are, however, behavior patterns which suggest greater need for follow-up after your surgery. For example, grazing, or non-mindful snacking and nibbling on high-calorie foods between meals can be a problem if not identified and stopped once you have had surgery. It is a pattern that significantly reduces your chances of success.

Your evaluation will probably include psychological testing, such as personality tests, mood inventories and other questionnaires. This paperwork is often completed before meeting with the psychologist. You will also have a face-to-face interview, usually scheduled for about an hour. It is often suggested that you bring a family member or close friend along to the interview if possible, since it is important to know that you have good family and social support. Results of the testing are usually discussed during this time, and the psychologist will want to know about your family and social history, any medical or psychological concerns you may have and your reasons and motivation for seeking the surgery.

You will also be asked about your past and present eating patterns, your level of activity and exercise and your current family and social situation. These guidelines are applicable to all physicians who are appropriately credentialed regardless of specialty and address the clinical situation in question.

The recommendations of each guideline undergo multidisciplinary review and are considered valid at the time of production based on the data available. New developments in medical research and practice pertinent to each guideline are reviewed, and guidelines will be periodically updated. Guidelines are not intended to provide inflexible rules or requirements of practice and are not intended, nor should they be used, to state or establish a local, regional, or national legal standard of care. Ultimately, there are various appropriate treatment modalities for each patient, and the surgeon must use judgment in selecting from among feasible treatment options.

ASMBS cautions against the use of guidelines in litigation in which the clinical decisions of a physician are called into question. The ultimate judgment regarding appropriateness of any specific procedure or course of action must be made by the physician in light of all the circumstances presented. Thus, an approach that differs from this guideline, standing alone, does not necessarily imply that the approach was below the standard of care.

To the contrary, a conscientious physician may responsibly adopt a course of action different from that set forth in the guideline when, in the reasonable judgment of the physician, such course of action is indicated by the condition of the patient, limitations on available resources or advances in knowledge or technology. All that should be expected is that the physician will follow a reasonable course of action based on current knowledge, available resources, and the needs of the patient, in order to deliver effective and safe medical care. The sole purpose of this guideline is to assist practitioners in achieving this objective.

The United States of America has experienced a steady rise in obesity prevalence over the last 20 years and currently ranks second in the world [6]. This trend is ominous, because morbid obesity predisposes patients to comorbid diseases which affect nearly every organ system. These include: type 2 diabetes, cardiovascular disease, hypertension, hyperlipidemia, hypoventilation syndrome, asthma, sleep apnea, stroke, pseudotumor cerebri, arthritis, several types of cancers, urinary incontinence, gallbladder disease, and depression []. Obesity shortens life expectancy [11] , with increasing body mass index BMI resulting in proportionally shorter lifespan [12].

With over , victims in the USA each year, morbid obesity is projected to overtake smoking as the leading cause of death in the near future [13]. There are now more than nine million morbidly obese Americans who need help. However, nonoperative management with diet, exercise, behavior modification, and medications rarely achieves adequate durable weight loss [14].

In the recent Swedish Obese Subjects prospective controlled study, medical management over ten years was associated with 1. Since the advent of minimally invasive therapies, there has been a dramatic increase in gastrointestinal procedures that produce significant sustainable weight loss with low complication rates []. Public awareness and demand, along with improved systems for surgeon training and delivery of care, have combined to fuel a national explosion in bariatric procedures.

In , , operations were performed in the USA, compared with only 13, in [26].

Management of patients post-bariatric surgery guideline

Operations to alter the gastrointestinal tract and produce weight loss have been applied for half a century. Weight-loss operations may cause malabsorption, restriction of food intake, or a combination of the two. The original operation for morbid obesity, the jejunoileal bypass, was first performed in However, this purely malabsorptive operation led to unacceptable morbidity and mortality related to bacterial overgrowth and liver damage [27]. Focus shifted away from purely malabsorptive procedures until the s when biliopancreatic diversion BPD was first described [28] , with eventual description of duodenal switch DS in [29].

This operation has been applied laparoscopically with effective weight loss [30]. Gastric bypass was introduced by Mason in as a combined restrictive-malabsorptive procedure [31]. Several variations and modifications of the original procedure have evolved over time, such as complete gastric transection, reduction in gastric pouch size, and application of a Roux-en-Y [32].

Laparoscopic RGB was popularized and validated in the early s by Wittgrove and Clark [33] , and several corroborating series have followed []. Differences exist in the technique for laparoscopic gastrojejunostomy as part of the procedure, including transoral circular stapler [33] , transgastric circular stapler [35] , linear stapler [36] , and handsewn [37] , but all are supported in the literature as producing similar safety and weight loss results. Mason and Printen developed a purely restrictive operation, the gastroplasty, in the early s [38]. This operation later developed into vertical banded gastroplasty VBG [39] , and ultimately laparoscopic VBG by the s [40].

Stomach banding for weight loss, originally introduced in the s with non-adjustable devices, became popular in the early s [42]. Laparoscopic adjustable bands quickly became popular worldwide because of the relative ease of placement and safety. Another contemporary restrictive procedure that derives from the concept of vertical gastroplasty is the laparoscopic sleeve gastrectomy LSG.

LSG developed as a first-stage procedure before duodenal switch or gastric bypass in high-risk patients [45, 46]. Studies have shown that LSG used in this manner reduces weight, comorbidities, and operative risk ASA score at the time of a second bariatric procedure []. There is increasing application of LSG as a primary weight loss operation [45, 46, 50, 51].

Evolving data demonstrate LSG provides substantial weight loss and resolution of comorbidities to years follow-up [45, 47, ]. There are other minimally invasive weight loss procedures in developmental stages. In addition, the expected benefits of operation must outweigh the risks. Surgery for morbid obesity has a low failure rate, with a mean EBWL of Mortality rates approximate 0. There are no absolute contraindications to bariatric surgery. Laparoscopic surgery may be difficult or impossible in patients with giant ventral hernias, severe intra-abdominal adhesions, large liver, high BMI with central obesity or physiological intolerance of pneumoperitoneum.

Surgeons performing bariatric surgery should possess the necessary skills to perform open bariatric surgery in the event it becomes necessary to convert to an open procedure [32]. One controlled trial of laparoscopic AGB in this group found superior weight loss, resolution of metabolic syndrome and improvement in quality of life versus medical management at 2-year follow-up [61].

Another report of 37 patients undergoing RGB showed excellent weight loss and near-complete resolution of comorbidities [62]. However, as endosurgical techniques and equipment have improved, laparoscopic RGB and AGB have been more liberally applied at extreme BMIs, with consequent health and quality-of-life benefits, acceptable rates of morbidity and mortality, but lower EBWL [].

Age restrictions are less rigidly employed in the current era of refined anesthesiology, effective critical care, and high quality surgical outcomes. Laparoscopic bariatric surgery has been performed in patients older than years [] , but with comparatively less weight loss, longer length of stay, higher morbidity and mortality, and less complete resolution of comorbidities compared with younger patients. Still, the reduction in comorbidities supports use of laparoscopic RGB or laparoscopic AGB in well-selected older patients []. At the time of the NIH consensus conference in , bariatric surgery for morbidly obese children and adolescents was not advised because of insufficient data.

However, with pediatric obesity increasing in prevalence and severity, interest in adolescent bariatric surgery is growing [84]. RGB is well tolerated and produces excellent weight loss in patients younger than 18 years with year follow-up []. Advocates believe weight reduction at an early age will prevent or minimize emotional and physical consequences of obesity [92]. Well-designed prospective studies are just emerging to better define the place for adolescent bariatric surgery [93].

The etiology of morbid obesity seems to involve genetic, environmental, metabolic, and psychosocial factors [94].

Therefore, treatment of the bariatric patient lends itself to a team approach for systematic evaluation and management [95]. Although a multidisciplinary team is seen as an important component of a bariatric surgery practice [32, 56, 96, 97] , no comparative clinical trials have proven this. The team leader is the surgeon, who is complimented by nurses, physician extenders and clerical staff for scheduling, insurance precertification, and coordination of patient flow.

Other important team members include nutritionists, psychologists with specific training and experience, and medical subspecialists endocrinologists, anesthesiologists, radiologists, pulmonologists, gastroenterologists, etc. The institutional needs of a bariatric program extend across outpatient and inpatient environments. It is important to have office and hospital furniture, equipment, clothing, fixtures, beds, and wheelchairs that are appropriate and comfortable for patients with morbid and supermorbid obesity.

In the operating room, specially rated tables and attachments, extra-long instruments, and appropriate staplers and retractors are necessary [97]. Healthcare providers and staff must be experienced with and sensitive to the special needs of bariatric patients, and protected against ergonomic and lifting injuries. Postoperative support groups are also an important aspect of a bariatric program and may improve postoperative results and limit relapse [32, 97, 98, 99].

Two nonrandomized studies have shown that patients attending support groups achieve greater weight loss than those who do not [, ]. Hospital annual case volume above may be associated with reduced morbidity and mortality and improved costs []. Higher surgeon volume has been associated with reduced mortality []. Center of Excellence designation programs have gained traction [95] and are maintained by the American College of Surgeons [] and the American Society for Metabolic and Bariatric Surgery []. The preoperative evaluation is similar for all bariatric procedures. Typical assessment includes psychological testing, nutrition evaluation, and medical assessment [97, ].

Patients with psychiatric disorders may have a suboptimal outcome after bariatric surgery []. However, no consensus recommendations exist regarding preoperative psychological evaluation [, ]. Many insurance companies require such psychological evaluation prior to granting precertification for a bariatric procedure. Nevertheless, the bulk of evidence shows no relationship between preexisting axis I psychiatric diagnosis or axis II personality disorder and total weight loss [, , ].

It is not certain which psychosocial factors predict success following bariatric surgery [] , yet many programs exclude patients who are illicit drug abusers, have active uncontrolled schizophrenia or psychosis, severe mental retardation, heavy alcohol use, or lack of knowledge about the surgery []. The nutrition professional is an integral part of multidisciplinary bariatric care [, ]. He or she is charged with nutritional assessment, diet education regarding postoperative eating behaviors, and preoperative weight loss efforts [].

Despite the wide utilization of preoperative nutritional efforts, and the requirement by many insurance companies for dietary counseling, data are still needed to prove association with postoperative weight loss or dietary compliance [, ]. No evidence-based, standardized dietary guidelines exist for either pre-or postoperative nutritional management of the bariatric patient, and no convincing data support the need for routine use of nutrition specialists after operation. Outcome studies and clinical trials are necessary to help define the role of the nutrition professional in the bariatric team.

Medical assessment prior to bariatric surgery is similar to abdominal operations of the same magnitude. Thorough history and physical examination with systematic review is used to identify comorbidities that may complicate the surgery. Consultation with a medical subspecialist is often necessary to optimize medical conditions to reduce perioperative risk. Routine laboratory evaluation typically includes complete blood count, metabolic profile, coagulation profile, lipid profile, thyroid function tests, and ferritin.

Bariatric Surgery: A Guide for Mental Health Professionals, 1st Edition (Hardback) - Routledge

Vitamin B12, and fat-soluble vitamin levels may be evaluated if considering a malabsorptive procedure. Cardiovascular evaluation includes electrocardiogram and possible stress test to identify occult coronary artery disease. Respiratory evaluation may include chest X-ray, arterial blood gas, and pulmonary function tests. Sleep apnea may be diagnosed by sleep study and the patient started on continuous positive airway pressure prior to surgery. Upper endoscopy may be used if suspicion of gastric pathology exists.

The liver may be assessed by hepatic profile and ultrasound. In cases of suspected cirrhosis, biopsy may be indicated. Ultrasound may be used to detect gallstones, allowing the surgeon to decide on concomitant cholecystectomy [98, ]. After jejunoileal bypass was abandoned [] , most of the bariatric community focused on restrictive operations []. However, Scopinaro revisited the value of malabsorption in his description of the BPD in the late s [28].

Since then, modifications have included the duodenal switch [] , the sleeve gastrectomy [29] , and the laparoscopic approach []. DS diminishes the most severe complications of BPD, including dumping syndrome and peptic ulceration of the anastomosis []. Sleeve gastrectomy spares the lesser curvature, vagus nerves and pylorus, in contrast to the original distal gastrectomy, though theoretical beneficial effects on eating behavior, weight loss and side-effects are not universally reported [, ].

The laparoscopic approach decreases wound complications, pain and hospital length of stay []. The bowel distal to the transection is elevated as an alimentary limb to the upper abdomen. Sleeve resection creates a tubularized stomach of approximately cm 3. The duodenum is divided 3 cm distal to the pylorus, and duodenoileostomy establishes continuity of the alimentary limb. Limb lengths determine weight loss and complications. A common limb that is too long will provide inadequate weight loss, whereas one too short will cause debilitating diarrhea and nutritional deficiencies.

Gastric remnant size should provide some restriction but not prevent initiation of protein digestion. A large Spanish series reports excellent outcomes with a common channel of 60 cm and an alimentary limb of cm [, ]. A US study suggests common channels longer than cm result in inferior results []. In a comparative study of outcomes and complications, cm common channel was superior to 50 cm, and sleeve gastrectomy was superior to distal gastrectomy []. Though there is a paucity of comparative data between open and laparoscopic BPD, a few comments can be made on the utility of the minimally invasive procedure.

Firstly, because the details of the resection and reconstruction are the same, long-term outcomes are likely to be similar. Indeed, at 1 and 3 years follow-up, weight loss is similar to that achieved by open surgery [, ].

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Laparoscopic BPD has reduced hospital stay and complications, mainly due to a lower rate of wound infections and dehiscence []. Laparoscopic BPD is an advanced, complex and feasible technique in bariatric surgery, and one which has a steep learning curve []. Weight loss is durable up to at least 5 years postoperatively. Weight may be regained over time [] , highlighting the importance of long-term follow-up. BPD dramatically impacts comorbidities. Data available are rarely randomized or controlled, and often compare non-equivalent cohorts.

Nonetheless, available data suggest the weight loss effect of BPD is greater and more durable than laparoscopic AGB [, ].

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A meta-analysis examining studies published between and found BPD resulted in more weight loss and improvement of diabetes, hyperlipidemia, hypercholesterolemia, hypertriglyceridemia, and obstructive sleep apnea than any other type of bariatric procedure [22].