Clinical Review

A guide for clinicians: Bariatric surgery and the ObGyn patient

OBG Manag. 2010 January;22(1):36-48

A boom in surgical weight-loss procedures means you will be called on to manage women who have undergone—or are considering—one of these operations. Are you prepared?

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IN THIS ARTICLE

Types of bariatric procedures
When is bariatric surgery indicated?
Potential complications
Nutritional concerns

References

1. Moore KA, Ouyang DW, Whang EE. Maternal and fetal deaths after gastric bypass surgery for morbid obesity. N Engl J Med. 2004;351:721-722.

2. Bariatric Surgery in Women of Reproductive Age: Special Concerns for Pregnancy. Structured Abstract. Rockville, Md: Agency for Healthcare Research and Quality; November 2008. Available at: www.ahrq.gov/Clinic/tp/barireptp.htm. Accessed Dec. 8, 2009.

3. American Society for Metabolic and Bariatric Surgery. Metabolic and bariatric surgery fact sheet. Available at: www.asmbs.org/Newsite07/media/asmbs_fs_surgery.pdf. Accessed Dec. 8, 2009.

4. Stellato TA, Hallowell PT, Crouse C, Schuster M, Petrozzi MC. Two-day length of stay following open Roux-en-Y gastric bypass: is it feasible, safe and reasonable? Obes Surg. 2004;14:27-34.

5. Oria HE, Carrasquilla C, Cunningham P, et al. American Society for Bariatric Surgery Standards Committee, 2004–2005. Guidelines for weight calculations and follow-up in bariatric surgery. Surg Obes Relat Dis. 2005;1:67-68.

6. Gastrointestinal surgery for severe obesity: National Institutes of Health Consensus Development Conference Statement. Am J Clin Nutr. 1992;55(Suppl 2):615S-619S.

7. MacDonald KG, Jr. Overview of the epidemiology of obesity and the early history of procedures to remedy morbid obesity. Arch Surg. 2003;138:357-360.

8. Buchwald H. Overview of bariatric surgery. J Am Coll Surg. 2002;194:367-375.

9. DeMaria EJ. Bariatric surgery for morbid obesity. N Engl J Med. 2007;356:2176-2183.

10. Cummings DE, Weigle DS, Frayo RS, et al. Plasma ghrelin levels after diet-induced weight loss or gastric bypass surgery. N Engl J Med. 2002;346:1623-1630.

11. Hallowell PT, Stellato TA, Schuster M, et al. Potentially life-threatening sleep apnea is unrecognized without aggressive evaluation. Am J Surg. 2007;193:364-367.

12. Hallowell PT, Stellato TA, Petrozzi MC, et al. Eliminating respiratory intensive care unit stay after gastric bypass surgery. Surgery. 2007;142:608-612.

13. Calle EE, Rodriguez C, Walker-Thurmond K, Thun MJ. Overweight, obesity and mortality from cancer in a prospectively studied cohort of U.S. adults. N Engl J Med. 2003;348:1625-1638.

14. Sjöström L, Narbro K, Sjöström CD, et al. Swedish Obese Subjects Study. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007;357:741-752.

15. Bray GA. The missing link—lose weight, live longer. N Engl J Med. 2007;357:818-820.

16. Kligman MD, Dexter DJ, Omer S, Park AE. Shrinking cardiovascular risk through bariatric surgery: application of Framingham risk score in gastric bypass. Surgery. 2008;143:533-538.

17. Linné Y. Effects of obesity on women’s reproduction and complications during pregnancy. Obes Rev. 2004;5:137-143.

18. Pasquali R, Pelusi C, Genghini S, Cacciari M, Gambineri A. Obesity and reproductive disorders in women. Hum Reprod Update. 2003;9:359-372.

19. Baeten JM, Bukusi EA, Lambe M. Pregnancy complications and outcomes among overweight and obese nulliparous women. Am J Public Health. 2001;91:436-440.

20. Lashen H, Fear K, Sturdee DW. Obesity is associated with increased risk of first trimester and recurrent miscarriage: matched case-control study. Hum Reprod. 2004;19:1644-1646.

21. Cnattingius S, Bergström R, Lipworth L, Kramer MS. Prepregnancy weight and the risk of adverse pregnancy outcomes. N Engl J Med. 1998;338:147-152.

22. Pathi A, Esen U, Hildreth A. A comparison of complications of pregnancy and delivery in morbidly obese and non-obese women. J Obstet Gynaecol. 2006;26:527-530.

23. Dao T, Kuhn J, Ehmer D, Fisher T, McCarty T. Pregnancy outcomes after gastric-bypass surgery. Am J Surg. 2006;192:762-766.

24. Stellato TA, Crouse C, Hallowell PT. Bariatric surgery: creating new challenges for the endoscopist. Gastrointest Endosc. 2003;57:86-94.

25. Poitou Bernert C, Ciangura C, Coupaye M, Czernichow S, Bouillot JL, Basdevant A. Nutritional deficiency after gastric bypass: diagnosis, prevention and treatment. Diabetes Metab. 2007;33:13-24.

26. Jin J, Robinson AV, Hallowell PT, Jasper JJ, Stellato TA, Wilhelm SM. Increases in parathyroid hormone (PTH) after gastric bypass surgery appear to be of a secondary nature. Surgery. 2007;142:914-920.

27. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999–2004. JAMA. 2006;295:1549-1555.

Fast Track

More than 200,000 people underwent bariatric surgery in 2008 alone—at least half of them women of reproductive age

Candidates for bariatric surgery include patients who have a BMI ≥40 and those who have a BMI ≥35 along with a comorbidity

Among adults 20 years and older in the United States, the prevalence of obesity is 32%, and the prevalence of morbid obesity is almost 5%

One of the most serious potential problems following Roux-en-Y gastric bypass is intestinal obstruction

Any physician who might care for a patient who has undergone a Lap-Band procedure should be aware of the possibility of a slipped band, a life-threatening complication

After Roux-en-Y gastric bypass, the patient should take a daily multivitamin, vitamin B₁₂, and supplemental calcium and vitamin D

CASE: New-onset abdominal pain and a history of bariatric surgery

A 28-year-old woman who is 14 weeks pregnant (G₅P₁A₄) complains of abdominal pain, nausea, and vomiting for the past 3 days. Four years ago, she underwent a successful Roux-en-Y gastric bypass, and her body mass index (BMI) decreased from 61.1 to 34.8 as a result. Today, after unremarkable ultrasonography at an outside hospital, she is transferred to your facility, where she is noted to be afebrile and tachycardic (133 bpm) with a very tender abdomen and a white blood cell (WBC) count of 12.2×10³/μL.

Could her symptoms be related to her history of gastric bypass? How should you manage her condition?

This case illustrates why it is imperative that Ob Gyns have a basic understanding of bariatric surgery—particularly the types of procedures being performed today and the complications that may arise.

In this case, urgent intervention is called for, given the elevated WBC count and extreme tenderness of the abdomen. This patient was taken to surgery without waiting for additional imaging studies. Operative findings included intussusception with necrosis, a late complication of the Roux-en-Y procedure, necessitating resection of 60 cm of small intestine ( FIGURE 1 ). Although fetal heart sounds remained encouraging overnight, fetal demise occurred the next day. The patient’s physical recovery was otherwise unremarkable.

This scenario is not as unlikely as you might imagine. A similar episode was described in 2004.¹ The outcome: maternal and fetal death.

FIGURE 1 Life-threatening intestinal obstruction

Patchy and continuous necrosis is evident following reduction of an obstruction-causing intussusception.

A boom in bariatric surgery

The incidence of surgical weight-loss procedures increased sixfold over a recent 7-year time span.² In 2008 alone, more than 200,000 people underwent this type of operation—at least half of them women of reproductive age.^2,3 In my experience at the University Hospitals of Cleveland Bariatric Program, which I directed, 85% of patients were women.⁴ This percentage is similar to the gender breakdown in other bariatric programs.

Because you are called on to provide both primary and specialty care, you are very likely to encounter women who have undergone bariatric surgery or who are considering it. As the prevalence of morbid obesity continues to rise, so will the need for familiarity with surgical weight-loss reduction.

In this article, I offer an overview of bariatric surgery, focusing on:

the different procedures performed today
the potential complications associated with the most common operations
the need for nutritional assessment.

In the process, I discuss the health benefits of bariatric surgery, including greater fertility and improved pregnancy outcomes.

How we talk about obesity

The language of obesity centers on a basic metric: the body mass index (BMI).⁵ This index was devised in the 19th century by Adolphe Quetelet to describe total body fat.

Consider its use to describe two markedly overweight individuals. One stands 6 ft and weighs 500 lb; the other stands 5 ft and weighs 400 lb. It is obvious which person is heavier; the BMI quantifies who is actually bigger. The first individual has a BMI of 67.8, whereas the shorter person has a BMI of 78, despite weighing 100 lb less.

The formula for determining BMI is:

Among the imperfections of the BMI are its failure to differentiate between genders and its marked inaccuracy in persons who have significant muscle mass and limited body fat, such as body builders. However, it does make it possible to compare patients of different height and weight, thereby facilitating attempts to prognosticate the risk of illness and identify candidates for bariatric surgery ( TABLE 1 ).

The 1991 National Institutes of Health (NIH) Consensus Conference on Gastrointestinal Surgery for Severe Obesity recommended that bariatric surgery (restrictive and bypass procedures) be considered for patients who have a BMI of 40 or above and for patients who have a BMI of 35 or above with high-risk comorbidity.⁶