bariatric

Question 1

post op tachy and ??

Answer 1

-anastomotic leak until proven otherwise
-water soluble contrast medium

Question 2

obesity statistics

Answer 2

-40% US population obese (>30)
-2.9% mil people in US with BMI >40
-74% adults are overweight or obese

-Men > 50% overweight = double mortality.
-Men > 50% overweight + DM = 5x mortality.
-Women > 50% overweight = 2x mortality.
-Women > 50% overweight + DM = 8x mortality.

-Class 3 obesity shortens life expectancy by 14 years.
-US $520 billion (2023; Congressional Report)

Question 3

issues linked to obesity

Answer 3

-CAD
-HTN
-Cerebrovascular Disease
-Type II Diabetes
-Lipid Abnormalities
-Metabolic Syndrome
-Cancer
-Osteoarthrtis
-Sleep Apnea
-Obesity Hypoventilation Syndrome
-Reproductive Abnormalities
-Gallstones

Question 4

bariatric surgery

Answer 4

-Bariatric surgery criteria
-BMI ≥ 35 kg/m2 without co-morbid disease.
-BMI ≥ 30-35 kg/m2 with concurrent co-morbid disease

->18 yo
-DM, HTN, severe sleep apnea
-nicotine and substance free
-psych
-physical and eating behavior
-team eval
-already significant risk for surgery on obese pts - anesthesia, DVT, etc

Question 5

roux-en-Y gastric bypass

Answer 5

-15-25 ml gastric pouch with 1cm outlet
-bypass distal to stomach, duodenum, first segment of jejunum
-bypass 75-150+ cm jejunum
-65-70% EBW loss
-decrease BMI 35%
-DM

Question 6

sleeve gastrectomy

Answer 6

-reduces the size of the stomach
-vertical - MC intervention

Question 7

LAP-BAND

Answer 7

-no physiological changes or resections
-band around upper stomach creates 15 ml pouch
-port of adjustment attached to abdominal wall
-inflate/deflate 6x a year
-50% EBW loss

Question 8

post surgical complications

Answer 8

-anastomosis leaks or staple line leaks
-PE or DVT- enoxaparin 2x day- 30 days
-cholelithiasis
-stomal ulceration
-dumping syndrome
-marginal ulcer- stomal ulceration due to mucosal erosion at a gastrojejunal anastomosis

Question 9

anastamosis leaks

Answer 9

-Up to 7-10 days after surgery.
-MC at gastrojejunostomy, enteroenterostomy, Roux limb stump, staple line
-Can lead to peritonitis, sepsis, possible death.

-Presentation:
-Tachycardia, tachypnea.
-Fever.
-Ab pain/back pain.
-Pelvic pressure or rebound tenderness!
-Oliguria

-1st notify surgeon
-Order water soluble upper GI series

-Subclinical cases:
-Bowel rest.
-NPO - Parenteral nutrition.
-IV antibiotic if H. pylori

-Clinically suspect leak:
-Laparoscopic evaluation or robot and leak repair.

-!!Failure to evaluate is the MCC of preventable, major long-term disability or death in bariatric surgical patients
-large ventral hernias

Question 10

pulmonary embolism

Answer 10

-Sudden cause of death up to 1 month after surgery.
-20%-30% mortality rate
-High risk may have vena cava filter placement prior to surgery- retrievable, below the renal veins
-Prophylaxis with compression stockings and LMWH.
-Early ambulation is imperative
-incentive spirometer

-Presentation:
-Profound hypoxia.
-Hypotension.
-Signs of sepsis

-Immediate spiral chest CT -> this is contrast so make sure they get IV fluids
-Abdominal exploration if too large for machine
-No pathology start anticoagulation.
-Too large…….NO SURGERY

Question 11

cholelithiasis

Answer 11

-Up to 36% of patients within 6 months post-op.
-NPO -> Bile stasis leads to increased sludge and gallstones.
-Prophylactic cholecystectomy prior to surgery if evidence of existing sludge or stones.
-Prevent post-operative disease with concurrent bariatric surgery and cholecystectomy.
-Prophylactic use of ursodiol: Expensive and unpalatable.

Question 12

stomal ulceration

Answer 12

-12%-15% within 2-4 mos. Post-surgery.
-Etiology:
-Too much acid in pouch results in excessive acid passing through stoma.
-Pouch tension and staple line breakdown.
-NSAID usage.

-Presentation:
-Dyspepsia, vomiting.
-Epigastric or retrosternal pain.

-Treatment:
-PPI, carafate.
-Antibiotics if H. Pylori.
-Avoid NSAIDS, alcohol, smoking.

-If no response to treatment:
-Endoscopy.
-Back to surgery for pouch revision or staple line repair

Question 13

dumping syndrome

Answer 13

-More than 15% patients.
-Hypotension.
-Tachycardia.
-Lightheadedness, syncope.
-Flushing.
-Abdominal cramping and diarrhea.
-Nausea and vomiting.

-Occurs with high dose simple sugar ingestion.
-Causes osmotic overload and fluid shift from blood to intestine.
-Increased intestinal volume -> water goes into bowel -> leads to watery diarrhea .
-Decreased blood volume leads to systemic changes -> hypotension

-Patient education:
-Eat slowly.
-Avoid drinking before, during and not until 30 minutes after meals
-no soda

Question 14

constipation

Answer 14

-MC complaint.
-Causes:
-Dehydration and decreased fluid intake post-operatively.
-more fat less water
-Increased metabolic water needs.
-Calcium and iron supplement use following surgery.

-Treat with increased fluids and stool softeners.

Question 15

nutritional consequences

Answer 15

-Iron deficiency anemia- duodenum
-B12 deficiency- ileum
-Folate deficiency- jejunum
-Calcium and Vitamin D deficiency.
-Not seen with purely restrictive surgeries -> bypasses (not balloons)

Question 16

iron deficiency and anemia

Answer 16

-Common following RYGB.
-As high as 49% of pt

-Multifactorial causes:
-Low gastric acid levels prohibit iron cleavage from food.
-Absorption inhibited because no nutrient exposure to duodenum or proximal jejunum.
-Decrease in iron-rich food consumption due to intolerance.

-Treat with oral supplementation of ferrous sulfate or ferrous gluconate.

Question 17

vitamin B12 deficiency

Answer 17

-Up to 70% of pts.
-Lack of hydrochloric acid and pepsin in stomach:
-Prevents B12 cleavage from food.
-Affects secretion of intrinsic factor (stomach), thus B12 absorption (ileum)

-Intolerance to meat and milk.
-Oral supplementation usually adequate, otherwise, IM injections used

-macrocytosis
-multisegmented neutrophils
-neurologic injury
-peripheral neuropathy
-dementia
-megaloblastic anemia
-replace folate (completely dietary quick onset) and B12 (long onset of deficiency) if you cant differentiate

Question 18

folate deficiency

Answer 18

-40% of gastric bypass patients.
-Complete absorption requires B12.
-Absorption dependent on HCl and upper 1/3 stomach.
-Deficiency generally caused by decreased consumption.
-Oral supplementation.

Question 19

vitamin D and Ca deficiency

Answer 19

-Vitamin D deficiency is common among obese people.
-Calcium absorption decreased because duodenum is bypassed.
-Intolerance to dairy, foods high in calcium.
-Vitamin D is required for Ca++ absorption.
-Prolonged deficiencies lead to:
-Bone resorption, osteomalacia, osteoporosis.

-Treat with calcium citrate supplementation and 2 weekly doses of Vitamin D.

Question 20

improvements of co-morbidities

Answer 20

-Type 2 DM
-HTN
-Hyperlipidemia.
-Degenerative joint disease.
-Sleep apnea.
-GERD.
-5% to 10% weight reduction is associated with significant decrease in risk!
-Weight loss from surgery reduces or eliminates medications
-Improves severity or resolves co-morbid disease.
-2 years after surgery DM was resolved in 83% of pre-operative diabetic pts
-2 years following surgery 69% had resolution of HTN:
-8 years post-surgery there was complete relapse in those with gastric banding.

-25% decrease in total cholesterol and 40% decrease in triglycerides 6 to 12 months after surgery

Question 21

psychological and psychosocial improvements from presurgical conditions

Answer 21

-Depression.
-Low self-esteem and self-appraisal.
-Poor interpersonal relationships.
-Feelings of failure and dissatisfaction with life.
-Subject to prejudice and discrimination.
-Obesity results in severe impairments of quality-of-life issues
-After surgery pts see the improvement in quality-of-life issues as the greatest benefit from bariatric surgery.
-They prefer a normal weight with a severe disability than to be obese without a disability.
-Greatest post operative benefits, as seen by patients were the improvements in physical and mental health

-Significant improvement in QOL with all types of surgery.

-New vocational and social activities.
-Improved interpersonal relationships.
-Better moods, self-esteem.
-More employable, get paid more, work more and take less sick days

Question 22

why do PAs need to know this

Answer 22

-We will be the long-term healthcare provider.
-Consequences and complications last a lifetime.
-Initial provider assessing signs and symptoms.
-Track improvements.
-Medication changes.
-Stay educated in all specific needs and concerns of bariatric surgery patient.