Bariatric Surgery Flashcards
Classification of Body Weight & Obesity
Primary & secondary obesity
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- Chromosomal & congenital anomalies
- Metabolic problems
- CNS lesions & disorder(s)
Secondary obesity
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- Excess caloric intake for the body’s metabolic demands
Primary obesity
! The majority of obese people have primary obesity (they’re eating too much & exercising too little; also are eating foods that are nutritionally deficient)
Patient Assessment
- Body mass index (BMI)
- Waist circumference
- Waist-to-hip ratio
- Determination of body shape
> BMI & waist circumference are widely used; they’re cost-effective & reliable in practice settings
Cardiovascular Problems
- Obesity is a significant risk factor for CVD
> Android obesity pts @ greater risk
* ↑ LDLs
* High TG’s
* ↓ HDLs
- Obesity is assoc w/HTN which occurs b/c of inc circulating blood volume, abn vasoconstriction, inc inflammation, & inc in sleep apnea which raises BP
- Altered lipid metabolism & HTN can lead to long-term risk of heart dz & CVA; excess body fat can also lead to chronic inflammation throughout body esp in blood vessels which can in turn inc risk of HD
Diabetes Mellitus
Type 2 diabetes
* Hyperinsulinemia
* Insulin resistance
* Glucose intolerance
! Weight loss & exercise improve glucose control
- More than 80% of people w/type 2 DM are obese or overweight
! A reduction of 7% of a person’s weight can reduce the risk of diabetes by 58%
GI & Liver Problems
- GERD
- Gallstones
- NASH
> Can eventually lead to cirrhosis
! Weight loss can improve
- Gallstones occur d/t supersaturation of bile w/cholesterol
- NASH occurs when lipids deposit in the liver, leading to a fatty liver
> Assoc w/elevated hepatic glucose production & can eventually lead to cirrhosis & be fatal
Respiratory & Sleep Problems
- Sleep apnea
> Snoring & hypoventilation - Obesity hypoventilation syndrome
> Reduced chest wall compliance
> ↑ work of breathing
> ↓ total lung capacity & functional residual capacity
The level of __ falls in patients who are sleep deprived, thus promoting appetite
leptin
Musculoskeletal Problems
- Osteoarthritis
> Stress on weight-bearing joints (knees & hips)
> Obesity triggers inflammatory mediators
> Cartilage deterioration
> ↑ incidences of hyperuricemia & gout
Cancer
- Obesity is 1 of the most important, known preventable causes of cancer
> Breast, endometrial, kidney, colorectal, & GB cancers are linked to excess body fat
- 20% in women; 15% in men
Psychosocial Problems
- Stigmatization
> Low self-esteem
> Social isolation
> Depression
- Discrimination in employment, education, & healthcare
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- A viable & popular option for treating obesity
- Currently the only treatment found to have a successful & lasting impact on sustained wt loss for severely obese individuals
Bariatric Surgery
Criteria for surgery
- BMI ≥ 40 kg/m2
- BMI ≥ 35 kg/m2 w/1 or more obesity-related complications
> HTN, type 2 DM, HF, sleep apnea
Must be screened for
- Psychological, physical, & behavioral conditions that have been assoc w/poor surgical outcomes
- Illnesses known to reduce life expectancy & not likely to be improved w/weight reduction
- Pts are not good candidates for bariatric surgery if they have untreated depression, binge-eating disorders, & drug & alcohol abuse that may interfere w/the commitment req’d to lifelong behavioral changes
Other criteria -
- Advanced cancer
- End-stage renal, liver, and cardiopulmonary dz
- Severe coagulopathy
- Inability to comply w/nutritional requirements
Bariatric Surgery - 3 broad categories
- Restrictive
- Malabsorptive
- Combination of restrictive & malabsorptive
___ surgery
The length of the SI is decreased, so there is less food absorbed
Malabsorptive
___ surgery
The stomach is reduced in size; there is less food eaten
Restrictive
A majority of these procedures are done laparoscopically, thus decreasing any postop complications or recuperation (as opposed to having an open procedure)
There are less wound infections, shorter hospital stays, & a faster recovery period
- Adjustable gastric banding (AGB)
- Vertical sleeve gastrectomy
- Vertical banded gastroplasty (VBG)
- Biliopancreatic diversion (BPD) w/duodenal switch
- Roux-en-Y bypass
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- Most common procedure
- Limits stomach size w/an inflatable band around fundus of the stomach
> Connected to a subcutaneous port then can be inflated or deflated to meet pt’s needs as wt is lost
! Creates a sense of fullness; can be modified or reversed @ a later date if necessary
Is this restrictive, malabsorptive, or both?
Adjustable gastric banding (AGB)
restrictive
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- 85% of the stomach is removed; NOT reversible
- Stomach function is preserved
- Results in elimination of hormones produced in the stomach that stimulate hunger (?)
Is this restrictive, malabsorptive, or both?
Vertical sleeve gastrectomy
ghrelin
restrictive
! Pts who are morbidly obese lose more wt w/this procedure
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- Has low complication rates
- Excellent pt tolerance
- Food bypasses 90% of stomach, duodenum, & a small segment of jejunum
Is this restrictive, malabsorptive, or both?
Roux-en-Y surgical procedure (RNYGB)
both
Roux-en-Y
- Is a robotic-assisted surgical procedure; results in quick wt loss but is more invasive w/a risk of postop complications
! Most commonly called “gastric bypass”
- Parts of the stomach are bypassed so fewer calories are absorbed
Combination Restrictive & Malabsorptive Surgery
- __ __ is common >RYGB
> Gastric contents empty too rapidly into the SI
> Avoidance of sugary foods is recommended
Dumping syndrome
Dumping syndrome
- N/V, fainting, weakness, diaphoresis, & sometimes diarrhea
> Eat smaller portions that are low in sugar; don’t drink liquids w/meals; we want to slow the process down
Preoperative Care
- Determine
> Assistive devices currently in use
> Past & current health info (comorbidities inc risk of complications) - A team approach may be necessary (cardiologist, pulmonologist)
- Have room ready for pt <arrival
- Larger BP cuff
- Larger gown
- Pt transfer equipment (wheelchair w/removable arms)
- Practice cough & DB, turning, & positioning procedures
> Teach spirometer use
> Arrange for CPAP if used @ home
- Obtain longer IV catheter
- May have NG tube placed
Postoperative Care
- Close observations for complications
- Transfer w/specially trained personnel
> Stabilize airway
> Manage pain
> Elevate HOB to 30-45°
- Evaluate for re-sedation
- Be on the lookout for thrombus formation, anastomosis leak, & electrolyte imbalances
> Ensure a patent airway when returning from surgery
- Diligent turning & ambulating
> Excess adipose tissue compresses chest & abdomen
! Causes CO2 retention
! Hypoxemia, PHTN, polycythemia
- Risk for DVT
> Anti-embolism stockings, SCD’s, low weight heparin - Infection (bacterial/fungal), dehiscence, delayed healing
Special Considerations: Postop Care
- Considerable abdominal pain
> Medicate as needed
> Assess for anastomosis leaks
> Evaluate wound condition closely
> Attentive to placement of NG tube
> Careful transition to new diet
> Monitor drainage & dressings; incision area
> If a pt vomits w/an NG tube in place, the tube may need to be repositioned; notify the surgeon immediately
Ambulatory & Home Care
- Following bariatric surgery, pts find it challenging to maintain a prescribed diet
> Pt now has reduced intake b/c of anatomic changes
> Attention to nutrition is important to prevent early &/or late complications
! Diet should be high in protein & low in carbs & fat; 6 small feedings daily; no fluids w/meals; restricted to <1000 mL/day
! In the late recovery phase we may see peptic ulcer formation, dumping syndrome, & small bowel obstructions
- Long-term follow-up care is important for physical & psychological reasons
> Old diet patterns
> Issues r/t the return of fertility in women
> New body image
Cosmetic Surgeries
- Ideal candidates have achieved weight reduction & have excess skin folds or fat
- Chooses surgery for cosmetic reasons; lipectomy/liposuction
Evaluation - Expected Outcomes
- Long-term wt loss
- Improvement in obesity-related co-morbidities
- Integration of healthy practices into lifestyle
- Improved self-image
- Monitor for possible adverse effects
Obesity: Gerontologic Considerations
- Increased prevalence of obesity
> Decreased energy expenditure contributes to inc body fat
> Exacerbates age-related problems
* ↓ mobility, urinary continence, hypoventilation, sleep apnea
- ↓ quality of life
- ↓ life expectancy by 6-7 yrs
