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Home Study Program

PERIOPERATWE CARE OF THE M T I E N T WITH MORBID OBESITY

he article Perioperative care of the patient with morbid obesity

is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared
by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, education program professional, Center for Perioperative Education.
A minimum score of 70% on the multiple-choice examination is
necessary to earn 4.6 contact hours for this independent study.
Participants receive feedback on incorrect answers. Each applicant who
successfully completes this study will receive a certificate of completion. The deadline for submitting this study is April 30,2006.
Send the completed application form, multiple-choice examination,
learner evaluation, and appropriate fee to
AORN Customer Service
c/o Home Study Program
2170 S Parker Rd, Suite 300
Denver, CO 8023 1-571 1
or fax the information with a credit card number to (303) 750-32 12.

BEHAVIORAL OBJECTWES

After reading and studying the article on perioperative care of the

patient with morbid obesity, the nurse will be able to
(1) describe overnutrition,
(2) compare medical and surgical treatment options for patients with
morbid obesity,
(3) define nursing considerations of caring for a patient undergoing
surgery for morbid obesity,
(4) differentiate between the types of surgical procedures available to
treat morbid obesity, and
(5) describe the postoperative course of a patient after having undergone surgical treatment for morbid obesity.
This program meets criteria for CNOR and CRNFA recertification,
as well as other continuing education requirements.

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Perioperative Care of the Patient

with Morbid Obesity

besity is the underlying pathogenesis of a

number of disease processes that are among
the top causes of mortality in industrialized
societies. Recently, it has been called an
epidemic.' In the United States, more than
60% of adults are overweight.' Obesity differs greatly from morbid obesity. Although obesity and morbid
obesity share numerous etiological factors (eg, genetic, environmental, psychosocial, economic), accepted
treatment options differ. Obesity deserves attention
and treatment to prevent potential complications.
Morbid obesity, however, requires urgent and definitive correction to treat both current and possible
future complications and to help prevent a probable
shortened lifespan. Currently, therapy for obesity and
obesity-related medical conditions costs nearly $1
trillion dollars per decade in the United States alone.'
CLASSIFICATIONS OF OVBRNUTRmON

States of overnutrition are classified based on

body mass index (BMI). This is calculated by dividing
a person's weight in kilograms by his or her height in
meters squared. Table 1 provides a simplified version

of the categories of overnutrition as described by the

American Society of Bariatric Surgery (ASBS) and
the National Institutes of Health (NIH)?
Using BMI as a measure of obesity can be misleading for very muscular people or people with little
to no central or abdominal fat. This problem, however,
is limited to people with BMIs less than 35. When a
person reaches a BMI greater than 35, measurements
such as waist to hip ratio and sagittal abdominal diameter become less important.' Patients are considered
candidates for surgical treatment if they previously
failed at medical weight loss attempts and are currently severely obese (ie, BMI > 35) with one or more
associated comorbidities or morbidly obese (ie, BMI
> 40) with or without comorbidities.
E f J i f s of obesity on body systems. Obesity
adversely affects almost all body systems and has
been associated with increased risk for a number of
malignancies. Table 2 lists those conditions and
comorbidities that occur more frequently in people
who are obese. This clearly supports the justification that care providers should aggressively treat
morbid obesity.

A B S T R A C T

COMPARlSON OF MEDICAL
VERSUS SURGICAL TREATMENT

Obesity recently has been called an epidemic. In the United

States, more than 60% of adults are overweight. Although obesity
and morbid obesity share numerous etiological factors (eg, genetic,
environmental, psychosocial, economic), accepted treatment
options differ. Morbid obesity requires urgent and definitive correction to treat both current and possible future complications and to
help prevent a probable shortened lifespan. Generally, it is accepted that nonsurgical approaches to weight loss for a person who is
morbidly obese are unsuccessful. This Home Study describes the
major surgical procedures currently available to treat morbid obesity and discusses the information that nurses need to know about
perioperative care of patients who are morbidly obese. AORN J 77
(April 2003) 802-819.

Few people who are obese

have benefited from medical
attempts at excess body weight
loss. Medical weight loss for people who are morbidly obese has a
95% failure rate and is extremely
unlikely to provide sustained
results, reduction of morbidity, or
improved survival. Generally, it is
accepted
that
nonsurgical
approaches to weight loss for a
person who is morbidly obese
consistently are unsuccessful. No

PAULA G R A L I N G , RN; H A Z E M E L A R I N Y , M D

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Table 1
intervention, other than surgery, has provided any
meaningful long-term success. This includes dieting, exercise regimens, psychotherapy, or prescription medications. The consensus, therefore, is that
for a person who is morbidly obese, surgery is the
only known effective treatment6
Success rate. Almost all available surgical
interventions result in an approximately 70% excess
body weight loss during the first year. Rather than
facing a 95% failure rate for nonsurgical excess
body weight loss interventions, the patient can be
offered a range of surgical interventions that offer
greater than 90% long-term success when using
35% excess body weight loss as the cutoff for success. When using 50% excess body weight loss as
the cutoff, the success rate still is better than 70%,
even for purely restrictive procedures. With bypass
procedures and biliopancreatic diversion, success is
even greater.
Complications. The international registry of
bariatric surgeries provides data regarding surgical
mortality and complications. Statistics demonstrate
an overall surgical mortality of 0.17% for patients
undergoing bariatric surgery and a complication
rate of only 8.5%.8Considering patients preexisting
conditions and the risks these patients automatically bring with them to the OR, these statistics represent very low numbers, suggesting that surgical
intervention not only is safe but also much safer
than lack of intervention. Failure to intervene surgically for these patients undoubtedly results in promulgation of their comorbidities with eventual morbidity and early mortality.
For these reasons, people who are morbidly
obese are candidates for surgical intervention.
These surgical interventions have low morbidity
and mortality and provide a significant and sustained excess body weight loss with reduction of
comorbidity rates and improvement in both survival
and quality of life for the patient.
SURGICAL APPROACHES TO THE
TREATMENT OF MORBID OBESITY

At Inova Fairfax Hospital, Falls Church, Va,

the approach to surgical treatment of morbid obesity is patient centered; therefore, no particular
weight loss procedure is preferred in comparison to
another. A person who is morbidly obese has the
right to choose between reasonably equal treatment
options. All procedures currently available in the
United States and generally accepted in the bariatric

CLASSIFICATION OF WEIGHT
BODY MASS INDEX (BMI)

BMI*

Cateaorv

< 18.5

Underweight

18.5 to 24.99

Normal

25 to 26.9

Overweight

27 to 30

Mild obesity

31 to35

Moderate obesity

36 to 40

Severe obesity

41 to45

Morbid obesity

> 50

Super obesity

* Measured in kilograms per meter squared

NOTE
1. Clinical guidelines on the identification, evaluation,
and treatment of overweight and obesity in adults,
National Institutes of Health, http://www.nhlbi.nih,gov
/guidelines/obesity/ob-exsum.pdf (accessed 30 Jan
2003).

surgical community are offered to patients seeking

primary treatment for their condition. Many patients
are extensively self-educated about their condition
and the available options and present with the decision already made regarding the specific procedure
desired. Others are unsure at the time of presentation and have done little research on their own to
learn about their options. Regardless of presentation, staff members educate patients extensively
regarding the history of bariatric surgical procedures and the evolution of procedures as a result of
outcomes and complications. Patients are informed
about procedures currently available in the United
States and procedures or devices not available in the
United States. Each surgical option is analyzed
carefully, and pros, cons, risks, and benefits are discussed in light of short- and long-term results,
weight loss, vitamin and malnutrition risks, and
early and late complication rates. Patients are told
that the decision primarily is theirs to make, but that
the decision should be based on
their specific physiology,
their personal and health goals,
a sound understanding of their eating behaviors,
the etiology of their obesity (ie, source of excess
caloric intake),

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Table 2
OBESlW-SPEClFK COMOABlDmES '

Cardiovascular
Atherosclerotic disease
Congestive heart failure
Hypertension
Varicose veins
Venous insufficiency and stasis
Dermatologic
Cellulitis
Dermatitis
Necrotizing infections
Panniculitis
Endocrinehetabolic
Diabetes mellitus
Glomerulosclerosis and renal failure
Gout
Hyperlipidernia

Urinary stress incontinence

Malignancies
Breast cancer
Colorectal cancer
Endometrial cancer
Gallbladder cancer
Ovarian cancer
Pancreatic cancer
Prostate cancer
Uterine cancer
Musculoskeletal
Bane demineralization
Carpel tunnel syndrome
Low back pain
Osteoarthritis
Neuropsychiatric
Depression
Idiopathic intracranial hypertension
Stroke

undergone a number of different

procedures. At the meeting, the
preoperative patient has the
opportunity to discuss particular
concerns. Only after this process
is complete is the patient actually
given an appointment to see the
surgeon for a physical examination. After the patient has been
examined by the surgeon, he or
she undergoes specific preoperative testing, and then the surgery
is scheduled. This allows the
patient ample opportunity to contemplate his or her options and to
give truly informed consent.
CALORIC INTAKE

The concept of weight balance or caloric equilibrium is

based on the concept of basal
metabolic rate, which says that
Ophthalmologic
each individual has a certain
Cataracts
daily caloric need that will result
Glaucoma
in neither weight gain (ie,
anabolism) nor weight loss (ie,
Pulmonary
Genitourinarv disease
catabolism). For most people,
Dysmenorrhea
Asthma
this is about 1,800 calories per
Hirsuitism
Obesity hypoventilation syndrome
day; however, for some it is less,
Infertility
Pulmonary hypertension
and for others it is more.
Polycystic ovarian disease
Sleep apnea
The simplified basics of
NOTE
weight balance. Patients who
1 . F Pi-Sunyer, "Comarbidities of oveweight and obesity: Current evidence
have gained excess body weight
and research issues,' Medical Science Sports and Exercise 31 no 1 1 suppl
have done so by consuming more
(November 1999) 602-608.
calories than their body needs on a
daily basis for a sustained period
of time. If weight gain is ongoing,
their risk tolerance, and
then excessive intake is ongoing. Weight loss
their ability to tolerate or accept the conse- requires that intake or absorption of intake be
quences or side effects of the particular proce- reduced below metabolic need on a daily basis for a
dures contemplated.
sustained period of time. This process achieves balThe preoperative educational process involves ance when the patient's total body size requires fewer
a full variety of medical personnel, including the calories for maintenance, and the patient is capable
patient's surgeon, a perioperative nurse, an anesthe- of consuming and absorbing an adequate quantity
and quality of nutrients postoperatively. Weight loss,
sia care provider, a dietician, and a psychologist.
The surgeon oversees the process, which generally therefore, stops when this equilibrium is achieved.
Reducing intake. How then can the caloric
is in the form of a two-hour presentation followed
by a question and answer session. Immediately after intake of a patient be reduced? The best approach is
this educational and information-gathering session, to determine where the excess calories are coming
the patient attends a support group meeting where from and eliminate (ie, restrict) that source or prehe or she is able to interact with patients who have vent that source of excess calories from being
Gastrointestinal
Abdominal wall hernia
Fatly liver
Gallbladder disease
Gastroesophageal reflux disease
Irritable bowel syndrome

~~

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Table 3
absorbed. To target these sources, patients
excess caloric intake sources are categorized.
These excesses are classified as
bloating-vereating
or eating large meals;
choosing-hoosing
the wrong foods at each meal
(eg, high fat, fried, high carbohydrate, low fiber);
grazing4onstant snacking during the day and
between meals or at night; and
sweeting-frequent ingestion of high calorie simple sugar-containing foods, drinks, or shakes.
Patients are asked to classify themselves to
determine where their excess calories come from. If a
patient reports that currently he or she does not consume excess calories, then the patient is asked where
the excess calories came from in the past. Most
patients can classify themselves into one or two categories. Patients who report that they have had stable
weight for more than one year likely truly have modified their diets to reach balance. These patients are
classified as normal to low metabolizers, depending
on their reported caloric intake.
The best judge of a patients need is the patient.
The only limiting factor is the patients knowledge
base. When the patient determines the source of his or
her excess calories, the appropriate procedure can be
chosen. This process is accomplished cooperatively
with the patient and his or her health care providers,
who consider all factors contributing to the decision,
including the patients weight loss goals, short and
long-term risk tolerance, and side-effect tolerance.

GLOSSARY OF BARIATRIC SURGICAL TERMS

Anastomosis
A newly established connection between two hollow
structures (ie, stomach to intestine, intestine to intestine,
intestine to colon, bile duct to intestine). This con be a
stapled, sewn, or mixed connection. Such connections
con be end to end, end to side, or side to end.
Band
~

A strip of tissue, mesh, tube, or device that is wrapped

around the stomach, port of the stomach, or pouch thot
serves to restrict the oufflow of food from one part of the
stomach or the pouch to another part of the stomach or
to on intestinal anastomosis,

Biliopancreatic limb
The segment of smoll bowel that starts at the second
portion of the duodenum where the bile duct enters the
duodenum and ends when and where it enters into the
Roux limb. This is the bile-carving limb.
Common channel
The segment of smoll bowel thot starts where the biliopancreatic limb enters into the Roux limb and ends at
the cecum. This is the segment where complex proteins,
fats, and carbohydrates ore best digested.
Pouch
The portion of the stomach that serves os o reservoir for
food immediately after food exits the esophagus.

Roux limb
The segment (ie, limb) of small bowel thot first receives
food, starting where food enters it and ending where the
biliopancreotic limb joins it.

pAnw SELECTION
The most important factor in achieving success
in bariatric surgery is patient selection and intervention selection. Most patients who present for evaluation for bariatric surgical procedures are selfreferred, determined to achieve change, and willing
to make personal lifelong sacrifices to achieve their
goals. Candidates who are not self-referred generally are reluctant, uncertain, and attached to certain
eating behaviors (eg, binge eating, specific food
addiction). These patients need to be counseled
extensively before undergoing surgery. Table 3 provides a glossary of terms common to many bariatric
surgical procedures.
Anatomical and historical considerations.
Figure 1 shows the normal anatomy of the gastrointestinal tract. The esophagus is the first passageway
into the stomach. Historically, interventions above
or at the level of the esophagus have not been effective for the treatment of morbid obesity. For exam-

Staple line
A row of staples fired into the bowel or stomach by a stopling device. A staple line can be within an anastomosis,
in a partition, or in o divided bowel end. One staple line
sometimes is incorporated into another or into o fully
hand-sewn anastomosis,

ple, wiring the teeth shut is ineffective because

patients nutritional source becomes high-calorie
liquids and shakes. Patients rapidly reach their
homeostatic or baseline level of nutritional intake
and, therefore, do not lose weight.
Some antireflux devices used in the past demonstrated that obstructive devices on the esophagus were
fraught with complications, such as erosion and
esophageal dilation. These devices, therefore, became
a nonviable option.
The esophagogastric junction (EGJ) and its

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Figure 1 Normal anatomy of the gastrointestinal

tract. All lengths are based on average findings of
nearly 550 cm total small bowel length beyond the
duodenum when measured laparoscoplcally and gently
stretched.

physiological function to relax for food passage and

tighten to prevent reflux is important. In patients with
significant reflux disease, certain procedures should
be avoided. The fundus of the stomach has a thin wall
and a great propensity to stretch, so this portion of the
stomach should not be used in the formation of a
pouch. The body of the stomach produces acid and
has a muscular digestive function for mixing chyme,
so it is not ideal for use in formation of a pouch.
The lesser curvature of the stomach is the thicker walled portion of the stomach that has less propensity to stretch and is more fixed in position. The
pylorus (ie, stomach outlet) is important in
regulating the output of the stomach to properly
limit acid output into the duodenum,
controlling chyme and other fluid output from the
stomach, and
preventing bile reflux between meals.

Denervation of the pylorus results in spasm and

obstruction. Disabling (ie, through pyloroplasty or
pyloromyotomy) or bypassing the valve results in
dumping syndrome because of unregulated emptying
of high solute concentration liquids, specifically
sweets, into the small bowel. Dumping syndrome is
defined as a symptom complex usually occurring
with sweet or sugar intake after a procedure that obliterates or bypasses the function of the pyloric sphincter. Symptoms can include faintness, palpitations,
nausea vomiting, low blood pressure, sweating, mild
to explosive diarrhea, or pain.
The antrum (ie, lower one-third of the stomach) is
important for two main reasons. First, it harbors G
cells that secrete gastrin, which is a paracrine and
endocrine hormone that stimulates acid production.
This is important when considering the larger pouch
of the biliopancreatic diversion procedure without
duodenal switch in which the endocrine gastrin effects
can increase pouch acid production and increase the
rate of ulceration if the antrum is not removed. This is
why a distal gastrectomy is recommended with larger
pouch procedures, such as biliopancreatic diversion
without duodenal switch. The acid also is important
when considering the duodenal switch procedure (ie,
longitudinal or lateral gastrectomy with preservation
of the pylorus and anastomosis to the duodenum) in
which preservation of antral acidification helps convert dietary iron to its absorbable oxidized ferric form.
Parietal cells in the antrum also produce an intrinsic
factor, a protein necessary for B,, absorption in the
ileum. The duodenum is important in the secretion of
a number of hormones, including secretin, cholecystokinin, and enteroglucagon. Leaving the duodenum
in the digestive food channel is believed to allow for
more normal gastrointestinal hormonal response to
meals, which helps provide an improved physiological
response to meals and improved satisfaction.
The bile duct, main pancreatic duct, and accessory pancreatic ducts illustrate the anatomical and surgical hazards associated with performance of the duodenal switch procedure and allow for an understanding
of its mechanism. Portions of the small bowel are
shown with their approximate unstretched lengths to
allow for understanding the sections of intestinal tract
used in various parts of the surgical procedures.
NURSING CONSIDERATIONS

It is important that perioperative team members

be familiar with the needs of a patient undergoing
bariatric surgery. Caregivers should consider the

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9

patients physical and psychological needs. Appropriately sized gowns and blood pressure cuffs, as
well as stretchers, must be readily available so that the
patient is made to feel welcome and not embarrassed
by the lack of attention to his or her size requirements. Additionally, specific education regarding
psychological needs of patients who are morbidly
obese is provided to preoperative personnel, including the registration clerk and holding area receptionist. Patients often view this day as the first day of the
rest of their lives. Unsolicited or inappropriate comments can spoil the experience for them, much the
same as spoiling a wedding day. Comments such as
you dont look like you need this surgery or oh,
but you really do carry your weight well may be
offered as compliments but can be perceived negatively by the patient. The patients family members
already may have accused the patient of taking the
easy way out by having surgery. Inappropriate comments may be reminiscent of past accusations of lack
of willpower or effort.
Preoperutivephuse. The patient usually is admitted to the hospital on the same day of surgery. He or
she is escorted directly from the registration area to the
preoperative holding area. In the preoperative holding
area, the preoperative nurse asks the patient to change
into a patient gown and wait on a stretcher for consult
with perioperative team members. The preoperative
nurse completes a patient assessment of vital signs,
reviews laboratory work for variations in normal values, and reviews the chart for completion of necessary
paperwork (eg, signed consent form, surgeons history
and physical examination).
The circulating nurse arrives from the OR to
greet the patient in the preoperative holding area. He
or she performs a brief assessment of factors affecting positioning, reviews the planned procedure, and
gives the patient and family members an opportunity
to ask questions. The circulating nurse then develops
a care plan specific to this patient and the procedure
being performed (Table 4). The patient remains in the
preoperative holding area until the anesthesia care
provider completes a preoperative assessment, places
an IV line, and administers a preoperative dose of
antibiotics. When the surgeon arrives and confirms
the planned procedure, the anesthesia care provider
notifies perioperative nursing team members and
transports the patient to the OR.
Intruoperutive phase. If at all possible, preoperative sedative medications are kept to a minimum
to facilitate patient transfer from the stretcher to the

OR bed. When in the room, the patient is assisted

with moving to the bed, which has specialized
hydraulics and padding to accommodate a patient
with morbid obesity. The anesthesia care provider
usually elevates the head of the bed to assist with the
patients respiratory effort. Awake positioning is preferred, particularly if the patient has multiple joint
limitations.
Positioning. Intraoperative team members work
cooperatively to place the patient in the supine position on the bariatric OR bed. The circulating nurse
places side bed attachments, if needed, for patients
with extra-wide girth. The circulating nurse places a
padded footboard on the foot of the bed to prevent
the patient from slipping when the bed is placed in
reverse Trendelenburgs position.
The anesthesia care provider helps the patient
extend his or her arms on arm boards, places padding
under bony prominences, and secures the patients
arm with cotton cast padding and hook and loop fastening straps. If the patient is undergoing a duodenal
switch procedure, the circulating nurse tucks the
patients left arm at his or her side to facilitate surgeon
positioning during measurement of the small bowel
limb segments.
The circulating nurse places a urinary catheter.
Several assistants may be needed to provide retraction of the panniculus and thighs for access during
catheter placement.
The circulating nurse places sequential compression devices on the patients lower legs and then
places a pillow under the patients knees to reduce
back strain. The nurse securely wraps the patients
legs with a soft blanket to support the legs in a comfortable position of thigh adduction with physiological external rotation and to avoid pressure on the lateral aspect of the lower leg and feet.
The circulating nurse places an electrosurgical
grounding pad on the patients left lateral thigh and
then places upper and lower temperature-regulating
blankets to maintain the patients body temperature.
Finally, the circulating nurse places two sets of safety
straps, one across the patients lower legs and the
other across his or her thighs.
Inducing anesthesia. Before induction of anesthesia, the circulating nurse and anesthesia care
provider question the patient about his or her comfort
to ensure that tissue is not pinched and placement of
extremities is comfortable. Anesthetic techniques are
the same as for any other abdominal procedure. The
anesthesia care provider continuously monitors the

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Table 4
NURSING CARE PIAN FOR A IP#TIEM UNDERGOING SURGERY FOR MORBID OBESITY

Nursing
diagnosis

Interventions

Interim
outcome criteria

Outcome
statement

Altered nutrition,
more than
body requirements related
to specific
eating patterns

Provides instruction to enhance patient's understanding of

mechanism for weight loss and need for nutritional
supplements.

The patient
verbalizes
understanding of
altered nutrition.

The patient
demonstrates
knowledge of
nutritional
requirements for
selected surgery.

Risk for anxiety

related to knowledge deficit and
stress of surgery

Determines knowledge level, assesses readiness to

learn, and identifies barriers to communication.

The patient
verbalizes
decreased
anxiety and an
ability to cope,
understanding
of individualized
procedure and
sequence of
events,
that questions
have been
answered, and
expected
outcomes.

The patient
demonstrates
knowledge of
the expected
response to the
procedure and
discharge care.

Explains sequence of events and reinforces teaching

about treatment options.
Provides instruction (ie, verbal, written) for surgical procedure and discharge based on age and identified need
and ensures availability of support group interaction.
Communicates patient concerns to appropriate surgical
team members.
Helps patient maintain self-esteem by obtaining
appropriately sized items (eg, gowns, wide stretchers,
fitted blood pressure cuff).
Evaluates response to instruction.

The patient participates in decisions affecting

his or her plan
of care.

Risk for altered

pulmonary
function related
to morbid
obesity and
hypoventilation

Assists with endotracheal intubation and ensures availabil- The patient

ity of difficult airway cart in the OR and continuous positive is extubated
airway pressure machine in the postanesthesia care unit. within 24 hours
postoperatively.
Monitors change in respiratory status.

The patient's
pulmonary function is consistent with or
improved from
baseline levels.

Risk for acute

or chronic
pain related
to surgical
procedure

Assess patient's pain preoperatively.

The patient
demonstrates
and reports adequate pain control throughout
the perioperative
period.

Identifies patient's accepted postoperative pain threshold.

Provides pain management instruction and pain scale to
assess pain control.

The patient
demonstrates
adequate pain
management.

Evaluates patient's response to pain management

interventions.
Risk for
injury related to
perioperative
experience

Verifies patient's identity, allergies, NPO status, and informed The patient's skin
remains smooth
consent.
Assesses skin integrity, sensory impairments, and muscu- and intact, and
neuromuscular
loskeletal status.
functions are
Transfers patient while awake using appropriate number of maintained or
assistive personnel, implementing protective measures to improved from
prevent positioning injury, and maintaining correct body
baseline.
alignment.
Evaluates for signs and symptoms of injury.
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The patient is
free from positioning injury
from extraneous
objects.

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patients vital signs, including pulse, blood pressure,

electrocardiogram, pulse oximetry, and end-tidal carbon dioxide. The anesthesia care provider anesthetizes the patient using a balanced technique of IV
induction and inhalation maintenance. Nitrous oxide
generally is avoided, as with most laparoscopic procedures, because it tends to diffuse into gas-filled
organs. This dilates the organs intraoperatively,
thereby obstructing the laparoscopic surgical view.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
and corticosteroids also are avoided for hematologic
and gastric reasons. For example, some NSAIDs,
such as IV ketorolac, are avoided because they can
cause gastric irritation and slow the healing process
of the fresh gastric staple and suture lines.
Additionally, routine use of dexamethasone is avoided to prevent gastritis and problems with healing and
to avoid confounding factors when evaluating the
patients laboratory results. The circulating nurse
ensures that an anesthesia cart specially stocked for
management of difficult airways, including a rigid
fiberoptic laryngoscope, is available in the room.
After intubation, the anesthesia care provider empties the patients stomach with a nasogastric tube.
The anesthesia care provider takes special care to
ensure the removal of all esophageal tubes during
insertion of sizing tubes, such as bougie dilators.
Prepping and draping. The nurse documents the
patients skin condition and measures used to prevent
injury intraoperatively. The circulating nurse performs an abdominal prep, including the skin folds
under the panniculus (ie, overhang of abdominal tissue). The circulating nurse ensures that the scrub person has extra draping towels, as needed. Surgical
team members perform standard draping for an
abdominal incision. The anesthesia care provider
places the OR bed in reverse Trendelenburgs position for easy access to the patients upper stomach.
For large patients, surgical team members may need
step stools to work within the sterile field.
AVAILABLE PROCEDURES

Numerous surgical procedures are available to

treat morbid obesity. These procedures differ in their
approach to anatomy and the desired outcome. Weight
loss or bariatric surgeries describe a broad group of
procedures whose subcategories include purely
restrictive (ie, limiting the amount of food intake),
gastric bypass, biliopancreatic diversion, purely malabsorptive (ie, reduced calorie and nutrient absorption), and neurostimulatory procedures (Table 5).

Vertical banded gastroplasty (VBC). Vertical

banded gastroplasty is a purely restrictive procedure
in which a small pouch (eg, approximately 15 mL to
30 mL) and a large liquid reservoir are created. No
stomach tissue is removed. It is best suited for
patients whose excess caloric intake source is bloating. This procedure often fails with patients who are
classified as grazers or whose excess caloric intake
source is sweets. It offers a low malnutrition or vitamin deficiency risk (l%), and patients require only
one multivitamin injection (MVI) daily. When successful, patients may expect a 60% excess body
weight loss. Specific complications include esophagitis, band erosion, or staple line failure. If revision is
needed as a result of liver or gastric scarring, an open
procedure usually is necessary because the VBG may
be difficult to revise (Figure 2).
Proximal gastric bypass. Proximal gastric
bypass is considered a mostly restrictive procedure.
Like the VBG, a small pouch is created without
removal of stomach tissue. A small 1-cm anastomosis is created with an intestinal bypass using a 100cm Roux limb, a short biliopancreatic limb, and an
approximate 400-cm common channel. The proximal gastric bypass works for patients who are classified as sweeters and bloaters but can be overcome
by patients who are classified as grazers. Patients
have some dumping syndrome but usually have little acid reflux. When successful, a patient may
expect 60% to 65% excess body weight loss. There
is a low early failure rate, and 20% to 25% of
patients experience a late (ie, after three years)
weight gain of 20% to 30%. Specific complications
include anastomotic ulcer and stricture and failures
that are converted to a distal bypass or duodenal
switch. (Figure 3 ) .
Distal gastric bypass. Distal gastric bypass is a
partially restrictive and partially malabsorptive procedure. As with other restrictive procedures, a small
pouch is created, and no stomach tissue is removed.
The anastomosis is small (ie, 1 cm) with a long Roux
limb, short biliopancreatic limb, and 100-cm common channel. The distal bypass generally eliminates
reflux but occasionally causes dumping. It is a viable
option for patients who are classified as sweeters,
grazers, and bloaters but can be overcome by persistent bad eating habits. There is a high malnutrition and
vitamin deficiency risk with distal gastric bypass, and
patients require 12 MVIs per day. Patients experience
a 90% excess body weight loss with a low early failure rate, but there is a possibility of mild weight

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* Grolirig * Elriinj*

Features
(ie, 500
cm unstretched
total bowel
length)

Vertical banded gastroplasty

Small 15-mL to 30-mL pouch
Large liquid reservoir
No malabsorption
Fails with sweeters and grazers
Best suited for bloaters
May worsen reflux if poor lower esophageal sphincter
No stomach removed

Proximal gastric bypass

Small 15-mL to 30-mL
pouch
Mostly restrictive
Causes dumping syndrome
Eliminates acid reflux
Works for sweeters and
bloaters
Grazers can beat the surgical procedure
No stomach removed
Small 1-cm anastomosis
1 00-cm Roux limb
Short (ie, 20 cm to 75 cm)
biliopancreatic limb
400-cm common channel

Distal gastric bypass

Small 15-mL to 30-mL
pouch
Partially restrictive
Partly malabsorptive
Can possibly cause
dumping syndrome
Usually eliminates reflux
Reasonablefor sweeters,
grazers, and bloaters
Can be beaten by persistent
bad habits
No stomach removed
Small 1-cm anastomosis
Long 400-cm Roux limb
Short (ie, 20 cm to 75 cm)
biliopancreatic limb
100-cm common channel

Weight
loss

When successful, can expect to lose

60% of excess body weight

Low early failure rate

20% to 25% late (ie, two
to three years) weight gain
Of 20% t0 30%
When successful, can expect
to lose 60% to 65% of
excess body weight

Low early failure rate

Possible mild weight regain
after two years
Can expect to lose 90% of
excess body weight

Malnutrition

Low malnutrition or vitamin deficiencv

risk (ie, < 1o/o)
Requires 1 multiple vitamin injection
(MVI) daily

Low malnutrition or vitamin

deficiency risk (ie, < 1YO to
2%)
Requires 1 MVI daily

High malnutritionand vitami& deficiency risk (ie, 10%

to 20%)
Requires 12 vitamin tablets
daily

Revision

Difficult to revise; however, if a revision

is necessary as a result of liver or
stomach scarring, it usually requires
an open procedure

Failures are converted to distal bypass or biliopancreatic

diversion with duodenal
switch

Sometimes needed to correct

malabsorption

Possible
late
complications

Esophagitis
Band erosion
Staple line failure

Anastomotic ulcer or stricture

Anastomotic ulcer or stricture

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COMPlWSON W THE TYPES OF SURGICAL PROCEDURES TO TREAT MORBID OBESlTY (CONTINUED)

Features

Billopancreatic diversion with duoVertical gastroplasty with sleeve

denal switch and vertical gasgastrectorny
troplasty/sleeve gastrectomy
Adjustable gastric band
Large 90-mL to 150-mL tubular
Large 90-mL to 150-mL
Micropouch
Purely restrictive
stomach
tubular stomach
Restrictive
Partially restrictive
Progressive slow compresDoes not change acid reflux but
Mostly malabsorption
sion to prevent hunger
reduces total acid producing capacity
May reduce acid reflux but
No stomach stapling
not nonacid reflux
Fails with sweeters and grazers
Can fail with sweets,
Usually performed with duodenal switch Works for sweeters, grazers,
shakes, and liquids
Performed alone to reduce risk in
and bloaters
Port placed on abdominal
patients who are super morbidly obese Can be beat with excess
wall
with intent to perform duodenal switch
eating of sweets or fat and
after 100-lb to 200-lb weight loss
overeating
Sometimes performed in selected
Wide open anastomosis
minimally obese patients (ie, < 350
150-cm Roux limb
Ibs) who wish to minimize bowel sur250-cm biliopancreatic limb
1 00-cm common channel
gery risk and are highly motivated,
nongrazers, and nonsweeters
Antral, pyloric, and duodenal
preservation
Preserves some antrum for better iron
and vitamin B,, absorption
Stomach segment resected
Preserves pylorus to prevent dumping
and removed from body
syndrome
Stomach segment resected and
removed from body

Weight
loss

Little need for long-term follow-up

Can expect to lose at least 65% of
excess body weight

High weight loss success

Can expect to lose 70%
to 75% of excess body
weight in first year
0 Can expect to lose 85%
to 90% of excess body
weight in second and
third years
Low failure rate with good
long-term follow-up

Malnutrition

Minimal malnutrition risk

Requires 1 MVI daily

5% to 7% malnutrition and
vitamin deficiency risk, especially vitamins A, 0,E, and
K and calcium

Low malnutrition risk

Requires 1 MVI daily

Revision

Easy to convert to or add duodenal

switch later
May allow for increased efficacy of
orlistat and phentermine

Revision may be needed to

treat malnutrition

Simple low-risk procedure

Reversible

Possible
late
complications

Delayed gastric emptying and reflux

Some bowel obstruction risk

Volvulus
Foul smelling stools and gas
Increased diarrhea, frequency, and urgency

Erosion
Slippage
Mega-esophagus

Variable

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9

per day. Success of this procedure provides the

patient with more than 65% excess body weight loss
at one year, although there may be failure with
patients who are classified as sweeters and grazers.
Specific complications relate to delayed gastric
emptying and reflux. The procedure may allow for
the increased efficiency of weight loss medications
and is easy to convert to a duodenal switch at a later
time (Figure 5). It is very easy for patients to consume more than 700 calories per meal if they make
poor food choices because of the larger remnant (ie,
pouch). For this reason, this procedure, when performed as the only planned procedure, is limited to
patients willing to carefilly monitor their caloric
intake and diet after surgery.
Biliopancreatic diversion (BPD) with duodenal switch, vertical gastroplasty/sleeve gastrectomy. This procedure was introduced approximately
15 years ago as an alternative to the Scopinaro BPD
and has several advantages. Specifically, the procedure depends more on malabsorption than restriction to accomplish weight loss, and this appears to
improve the long-term success rate. The absence of

Figure 2

Vertical banded gastroplasty.

regain after two years. Specific complications are

anastomotic ulcer or stricture, and sometimes revision is needed to correct malabsorption (Figure 4).
This procedure generally is discouraged because it
carries the highest risk with regard to malnutrition as
a result of the small pouch in combination with a
short common channel. A duodenal switch procedure
is preferable for patients who need malabsorption.
Vertical gastroplasty with sleeve gastrectomy.
The vertical gastroplasty with sleeve gastrectomy is
a restrictive procedure usually performed with a
duodenal switch. It may be performed alone to
reduce perioperative risk in a patient who is extremely morbidly obese with the intent of performing the
duodenal switch as a second stage after a 100-lb to
200-lb weight loss. Anatomically, the vertical gastroplasty with gastrectomy leaves a tubular stomach,
which preserves some antrum for better iron and B,,
absorption. It does not change reflux, reduces total
acid producing capacity, and preserves the pylorus so
there is no dumping syndrome. There is little malnutrition risk, and the patient usually takes one MVI

Figure 3

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Proximal gastric bypass.

APRIL 2003, VOL 77, NO 4

Gruling E1urin.v
9

a gastro-enteric anastomosis reduces marginal ulcer

and stricture risk. Leaving the pylorus functional
avoids the dumping syndrome, and antral acidification of iron and flow through the duodenum and
antral gastrin secretion improves iron and vitamin
BU absorption, thereby almost eliminating the risk
of these deficiencies. The procedure generally has
been reserved for patients with higher BMIs (ie,
greater than 45) but in recent years has been offered
to patients with lower BMIs (ie, 35 to 44) with good
results and low morbidity. More than 250 laparoscopic duodenal switch procedures have been performed at Inova Fairfax Hospital with no deaths,
low morbidity, and excellent weight loss results.
The duodenoenteric anastomosis was performed
using a laparoscopic handsewn method without
leaks in the last consecutive 200 procedures. The
procedure is not without its drawbacks, however,
and it does have a higher malnutrition risk (ie, 5% to
7%) than proximal bypass. It also has associated
side effects of steatorrhea and foul stool and gas,
especially with fatty and carbohydrate rich foods.
There is a higher incidence of vitamin D and calciFigure 5 Vertical gastroplasty with sleeve gastrectomy without banding.

Figure 4

Distal gastric bypass.

um malabsorption, and vitamin A dosing becomes

an issue during pregnancy. Patients who choose this
procedure generally are very happy with it because
the larger meal size is important to them and the
absence of dumping syndrome also is relevant.
Patients, however, must be compliant with vitamin
and protein intake, or malnutrition will develop
(Figure 6).
Adjustable gastric band (AGB). The AGB procedure is ideal for patients who are afraid of highly
invasive procedures and want a simple, easily
reversible procedure to help with portion control.
Patients might say that they like that there is no stomach stapling, removal, or rearrangement. Patients also
must desire the adjustability, which allows them to
ease into it with progressive needle adjustments, and
they cannot mind the needle adjustments. Patients
must be willing to comply with sweet and snack
avoidance postoperatively to see success (Figure 7 ) .
Non-FDA approved options. Use of the gastric
balloon has been difficult to revive in the United
States. A variant of gastric balloon was available in
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8

the United States in the 1980s but was banned due

to the complication rate. The current version is
modified and has lower bleeding or obstruction
complication rates; however, the efficacy is shortlived and minimal compared with the better than
50% excess body weight loss seen in other currently used bariatric procedures. It usually is used in
Europe as a bridge to weight loss in patients who are
morbidly obese.
A modified cardiac pacemaker may be used to
reduce appetite by inducing a feeling of satiety. The
electrodes are placed in the muscle. Electrical
impulses from the device reduce appetite and stimulate the muscles and the nerves on the muscles to
contract, which speeds up stomach emptying. The
gastric pacemaker still is investigational. Very little
literature exists regarding its effectiveness and complications (Figure 8).
AFCER C O M M O N OF THE PROCEDURE

Figure 6 Biliopancreatic diversion with duodenal

switch and vertical gastroplasty/sleeve gastrectomy.

The surgeon performs an intraoperative endoscopy with pressure insufflation and leak test at the
end of the surgical procedure. The surgeon places a
drain before closure if the patient had an anastomosis,
which facilitates early diagnosis of an anastomotic
leak. At the completion of the procedure, the

Figure 7 Adjustable gastric band.

Figure 8 lntragastric balloon (0) and vagal pacing (b).

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Intake gradually is advanced during the next few

days. For example, on days three and four, the diet is
advanced according to tolerance. The patient is
expected to walk daily and regularly and sit in a
chair when not walking. If tolerating liquids well,
the patient may advance to a low carbohydrate, full
liquid diet as early as the third postoperative day.
The patient stays on this diet for two days.
Medications must be crushed or opened. Common
medications include ursodiol (ie, if gallbladder was
not removed), pain medications, lansoprazole, multivitamin with iron, and medications previously prescribed for chronic medical conditions. On the fifth
and sixth postoperative day, the diet continues to
advance. The patient now should be able to safely
begin eating pureed foods, including baby foods,
applesauce, blended soft foods, and potted meats.
The patient needs to drink constantly to remain
hydrated. The patient will not need to supplement
with protein powder during these early days. On the
sixth and seventh day, the diet progresses to soft
foods, including all of the previously mentioned
pureed items, all allowed liquids, and soft foods,
such as baked white fish without bones, imitation
crab meat, hot dogs, canned fruits, and over-cooked
vegetables. Hard meats, such as steak, pork, and
chicken, are not allowed.
During the second through third weeks, the
patient begins a regular food trial period. This
includes all previously allowed items plus red meat,
chicken, and well-cooked vegetables. This is called a
trial period because patients are expected to try only
one new item at a time. If adding one new regular
food per day, 14 new items have been added by the
end of this period. The patient also may begin trying
to take whole pills, one at a time, during this period
rather than crushing them.

incision is injected with 0.25% bupivicaine to assist

with pain management. The anesthesia care provider
extubates the patient in the OR, and surgical team
members transfer the patient to a bed equipped with
specialized padding and sturdy hydraulics. The anesthesia care provider and nurse then transport the
patient to the postanesthesia care unit (PACU).
POSTOPERATIVE CARE

The patient spends approximately one hour in

the PACU and then is taken to the surgical floor. The
patient may be admitted to a critical care unit if he or
she is experiencing shortness of breath, needs continuous positive airway pressure, or has complex
medical conditions requiring continual observation
and care.
Depending on the details of the surgery, patients
may awaken with a nasogastric (NG) tube in place. It
also may be necessary to perform an x-ray leak test
after surgery. This usually is done on the first or second day after surgery, as needed. If it is needed, the
patient is taken to the radiology department. The
radiology technologist gives the patient clear x-ray
contrast medium to sip at specified times during the
procedure. The radiologist takes several x-rays as the
patient swallows the contrast medium. The technologist prints the x-rays, and the radiologist and surgeon
carehlly review the results. A decision is made
whether to leave the NG tube in place and when to
start the patient on a liquid diet. At Inova Fairfax
Hospital, the first 50 patients all had postoperative
esophagograms. With program maturity and a leak
rate of 0%, esophagograms now are used only for a
select group of patients.
Each bariatric procedure has its own specific
postoperative instructions, which are tailored in detail
to the type of procedure. If surgery was performed
laparoscopically and the patient is able to tolerate liquids, discharge to home may be accomplished on the
same day as surgery. As with any laparoscopic procedure, patients have smaller scars, reduced pain,
decreased length of stay, and shorter recovery time
compared to open surgery. All patients receive antibiotic coverage, respiratory support (eg, nebulizer,
incentive spirometry), patient-controlled analgesia,
and sequential compression stockings and enoxaparin
sodium to minimize deep vein thrombosis. Table 6 is
a sample set of orders for a patients day of surgery
and first postoperative day.
Dietary instructions. For the first two days after
surgery, dietary intake is limited to clear liquids.

PosToPERAmfE rnUoW-UP

The patient is instructed to be as active as possible, walking up to one mile per day by the postoperative office visit. He or she also is instructed to
wear an abdominal binder while active. Activity
gradually is increased; however, the patient is
instructed to avoid heavy lifting for three to six
weeks after surgery to allow the incisions to heal
solidly. The patient may return to work one week
after surgery if he or she underwent a laparoscopic
procedure. If the patient underwent an open procedure, he or she may be able to return to work approximately six weeks later.

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Table 6
PO?STOPERATMORDERS FOR LAP#ROSCOPICGASTRIC BYPASS PROCEDURES'

Day of surgery

(IVP) q 4 hrs PRN for nausea

Acetaminophen 100 mg suppository per rectum (PR) q 4 hrs
PRN for headache or temperature
> 101" F (38.3" C)
0 Diphenhydramine 25 mg IVP
q 6 hrs PRN for itching or
insomnia
0

Activity: help patient out of bed and

into bedside chair twice before bedtime; no straining or heavy lifting
Diet: nothing passed orally
IV: 5% dextrose in .5% normal
saline (NS) with 20 mEq
potassium chloride at 125 mVhr

Oxygen at 2 L per nasal canula

while awake; continuous positive
aiiway pressure when sleeping

Medications:
o Check blood sugar every (9) 6
hrs, then administer subcutaneous (SQ) humulin regular
insulin using the sliding scale
Blood sugar
180-200
201 -250
25 1 -300
30 1-350
3 5 1-400
401 -450
5 units IV then

> 450

Dose
2 units SQ
4 units SQ
6 units SQ
8 units SQ
10 units SQ
10 units SQ and

Albuterol 0.5 mL in 3 mL NS q 4
hrs and add intermittent positivepressure breathing at 10 if poor
effort identified
Bilateral lower extremity sequential
compression devices (SCDs) over
thromboemboletic stockings
Vital signs per routine

Postoperative day one

Activity: as tolerated; no straining
or heavy lifting

recheck blood
sugar after 3 hrs
Same and call
physician

Cefotetan 2 g IV piggyback
(IVPB) q 12 hrs for three postoperative doses, if not allergic
o Famotidine 20 mg IVPB q 8 hrs
for three postoperative doses
o Patient-controlled analgesia per
anesthesia care providers; discontinue (D/C) on postoperative
day two and switch to fentanyl
patch 50 mcg/hr
o Enoxaparin 4 0 mg SQ two times
per day (bid) starting late tonight
o Pramethazine 25mg IV push

Diet
0 Call resident for diet when upper
gastrointestinal series results
have been received
o Advance diet to full liquids then
to low carbohydrate (ie, diabetic)
clear liquid diet; patient may
dilute juices 50/50

I V D/C when diet started

Laboratory tests: complete blood

count, chemistry profile, chest
x-ray, electrocardiagram, and pulse
oximetry
0

Medications: crush all medications

to a powder or open capsules, then

administer in sherbet
0 Ursodiol 300 mg taken by mouth
(PO) bid if patient has not had a
cholecystectomy
0 Fentanyl patch 2 5 mcg per hr
PRN for pain
0 Acetaminophen/oxycodone one
to two tablets q 4 to 6 hours
PRN for pain if fentanyl patch is
not adequate
0 lanoprasole 30 mg PO q day
0 Acetaminophen 1,000 mg liquid
PO q 4 hrs PRN for headache or
temperature > 101 F (38.3 C) if
tolerating oral intake
o D/C meperidine
O

Bilateral lower extremity SCDs over

thromboemboletic stockings
0 Remove SCDs when patient is
ambulating
o Replace SCDs when patient is
lying in bed or sitting in chair
Discharge patient to home
0 Ensure patient is tolerating oral
medications and liquids
o Provide patient with male urinal
or female toilet hat for at home
monitoring of urine output
Provide prescriptions for
0 Fentanyl patch 25 mcg per hr
PRN for pain
o Acetaminophen/oxycodone 1 to
2 tablets q 4 to 6 hrs PRN for
pain if fentanyl patch is not
adequate
o lanoprasole 30 mg PO q day
o Ursodiol 300 mg PO bid
o Promethazine 25 mg PR q 4 hrs
PRN for nausea

NOTES
1 . H A Elariny, 'Postoperative instructions after open and laparoscopic gastric bypass," Advanced Laparoscopic and
General Surgery Associates, http://www.alagsa.com/GBP-lnstr.htm (accessed 30 Jan 2003).

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The patient must keep a record of exactly what

and how much he or she eats and drinks at every
meal for the first three weeks after surgery. This is
the only way the surgeon can determine whether
dietary protein intake is adequate. The patient
should bring the dietary log to the first postoperative
visit. If the patient has diabetes, he or she probably
will have reduced or discontinued medicines and
must check his or her blood glucose twice daily to
determine whether adjustments are necessary.
Follow-up appointments are scheduled once per
month for the first year, during which the patients
weight is checked. Laboratory work is completed
(eg, hemoglobin, albumin, electrolytes, vitamin levels) six months after surgery, or sooner if the patient
reports that he or she is eating poorly, to detect any
vitamin deficiencies.
Long-term support. A bariatric support group
for preoperative and postoperative patients is held
once per month by the surgeon. Each week, patients
of specific surgical types hold their own support
group, which is moderated by a patient. After weight
loss, the patient may need to return to the OR for a
secondary procedure. Sagging skin in the face,
arms, breasts, and abdomen may lead to functional
and aesthetic deformities. Skin folds may conNOTES
1. A H Mokdad et al, The
spread of the obesity epidemic in the
United States, 1991- 1998,JAMA
282 (Oct 27, 1999) 1519-1522.
2.Ibid.
3. M M Ellison, H E Mulcahy,
Obesity: Weighing up the cardiovascular risks, British Journal of
Cardiology 8 (February 2001) 61-64.
4. Rationale for the surgical
treatment of morbid obesity,
American Society for Bariatric
Surgery, http://www.asbs.orgihtml
/ration.html (accessed 30 Jan 2003).
5.Clinical guidelines on the
identification, evaluation, and treatment of ovenveight and obesity in
adults, National Institutes of Health,

tribute to problems with hygiene and may cause

chronic skin inflammation or infection. The patient
may seek consultation with a plastic surgeon for a
face lift, marnmoplasty, or abdominoplasty for
removal of excess skin.
The commitment to the bariatric patient does not
end when the immediate perioperative period is complete. Administration of a comprehensive bariatric
program encompasses many aspects besides the surgical intervention. A successful program includes nutritional support, psychological support, and availability
of practitioners to help with any complications experienced by the patient. More than 500 procedures have
been performed since inception of the program in
1999 at Inova Fairfax Hospital. Patients report a 100%
satisfaction rate, a decrease in comorbidities, and
greater enjoyment of their healthier lifestyle. A

Paula Craling, RN, MSN, CNOR, CNS, is the clinical

nurse specialistfor perioperative services at Inova
Fairfar Hospital, Falls Church, k .
Hazem Elariny, MD, PhD, is a surgeonfor Advanced
Laparoscopic and General Surgery Associates, Arlington,
k.

http://www.nhlbi.nih.gov/guide
lines/obesity/ob-home.htm(accessed
30 Jan 2003).
6.G S Cowan, Jr, A predicted
hture for bariatric surgery: Using the
surgical model, Obesity Surgery 6
(February 1996) 12-16;S AbuAbeid, A Keidar, A Szold, Resolution of chronic medical conditions
after laparoscopic adjustable silicone
gastric banding for the treatment of
morbid obesity in the elderly,
Surgical Endoscopy 15 (February
2001) 132-134;M Deitel, Surgery
for morbid obesity. Overview,
European Journal of Gastroenterology and Hepatology 1 1
(February 1999)57-61;A M Glenny
et al, The treatment and prevention

819
AORN JOURNAL

of obesity: A systematic review of

the literature, International Journal
of Obesity and Related Metabolic
Disorders 21 (September 1997)715737.
7.A M Macgregor, The patient
factor, Obesity Surgery 6 (August
1996)325-329.
8. Obesity epidemic puts millions at risk from related diseases:
Press release 12 June 1997,World
Health Organization, http://www
.who.intarchives/inf-prl997/en/pr97
-46.html (accessed 30 Jan 2003).
9.Ibid.
10.S J Pavlovich-Danis, Bariatric
surgery update, The Nursing
Spectrum 1 1 (September 2001) 1417.