Bariatric Surgery Flashcards
Obestiy Epidemic and epidemiology
relation to otehr disease
Epidemic
- increased prevelence
- kids increasing
- 41% of the US
- costs billions
Epidemiology- complex and multifactorial
- exercsie and nutrtion
- genetics
- social status
- gut microbome
- psychology
- hormones
- viruses etc.
Obestiy = inreases your risk
-for a multitude of conditions, cancers, sleep issues, psychological issues and infections
Indications and Contraindications for Bariatric Surgery
Indications
- 35-40 BMI with obestiy releated health issues
- health issues = HTN, HLD, OSA, DM
- 40+ BMI with or without obestiy related issues (some now allow 30 + issues)
Contrindications
- uncontrolled mental health condition
- uncontrolled endocrine dysfunction (DM or thyroid)
- unable to understand or commit to lifelong follow up and treatment
Pre-Op Optimization
what does this mean
how does ithelp with outcomes
what type of plan
Pre-Op optimization
- educate on lifestyle cahnges
- dietian to help set up goals for diet and supplemetns
- PT consult for exercise
- sometimes WL before surgery is necessary
Weight loss Medical Management
- nutrtion
- movement
- behavior
- medication
- surgery
Bariatirc Surgery + Medical WEight Loss management
- they go hand in hand
weight management before surgery = improved outcomes
- better surgery, recovery, mental preparation and improves otehr health issues
- enhances overall weight loss and decreases weight stalls and reduces post-op gain
Bariatric Surgery overview
types
open v lap.
98% of the surgeries are laproscopic/robotic v. open
- adjustable gastric band (rare)
- vertical sleeve
- bypass (roux-en-Y)
- single anastomosis duodenal illeostomy
- biliopancreatic diversion with duo. switch
Sleeve Gastrectomy
type of procedure
positive outcomes
Negatives
Sleeve Gasterectomy
- stomach size reduced by 85% to a banana shape
- no rerouting of the organs
- allows for weight loss in 2 ways : physical and psychological
- #1 = decreased stomach size = feel full
- #2 = decreased grhelin hunger hormone
- most commony procedure done in the US
quick procedure and allows for 60% of excess weight lost
Downside
- can have an increase in reflux post-op because theres increased pressure (less room)
Roux-en Y Gastric Bypass
Procedure
- egg-shaped pounch og the upper stomach is created: this is the “new stomach”
- meaning: you can only eat 1 cup of food at a time
- hard to eat and drink at same time
- small area = increased full feeling
- then the intestines are rerouted to bypass first 1/2 of SI = decreases absorbtion
- the rest of teh stomach remains to release gastric jucies and bile into the intestines later on (but it wont recieve food)
Postive Results
- 60-80% excess weight loss
Negatives
- lots of replacements: iron and Ca2+
- nee diet control: dumping syndrome: no sphincters so if you eat too face it shoots right inot duodeum an dlower SI and causes intense pain with fat and sugar intake
SADI : single anastamosis Duodeno-illeostomy
Procedure
- a smaller stomach is created (like the sleeve) a banace shape
- rest of stomach is removed
- then, the duodenum is cut and connected to the lower illeum
- resulting in a bypass of teh SI: decreased absorbtion
POstives
- a singel connection
- longer common channel at the end
Duodenal Switch
Procedure
- creates a small banana shapped stomach like the sleeve
- other portion of stomach removed
- 2/3 of the SI is bypassed = less calories absorbed
- (restricting and malabosrbing)
- the bypassed intestines stay, and reconnected to the bottom to allow for jucies to pass through here
Postives
- a huge reduction in the DM!!! up to 98% have their DM gone : because youre impacting gut homrones of leptin, GLP etc.
- lots of weight loss = 70-80% of excessive
Negative s
- 2 anastamosis sites
Benefits of Bariatric Surg. v Risks
Benefits
- weight loss long term
- improved or resolution of chornic conditiosn like : DM, HTN, sleep apnea, HLD
- duodenal switch: lots of HLD and DM reoslution
- portion control
- inproved QOL
Risks
- vitamin and nutrient deficiency
- BLOOD CLOT = #1 risk
- dehydration
- acid reflux
- N/V
- infection
Lifestyle changes after bariatric Surgery
Supplementation
- mutliple vitamins and supplemetns
Eating
- protien first mentality, low fat and carb
movement
- 150 mins of moderate exercsie weekly
support groups and lifelong follow up needed
Risk Factors that make Bariatric Surgery difficult
low mortality rates: highest within first 30 days – but super lowe overall
Risk Factors
- male
- older age
- high BMI at baseline
- poor functional status at abase
- open surgery or need for revisional
- longer OR time
- smoker within last year (marajuana: must quit 30 days before, swap to nonsmoked form stop 7 days before)
preop comorbidites
- COPD, pulm thormoembo, HTN, previosu surgery, uncontrolled glucose, anticoag or abnormal albumin
- will not operate if A1C > 8 or BG > 200
PONV with Bariatric Surgery
common!
- can increase stay and morbitiiy
- risk of PNA, esophageal rupture, incisional rupture, etc.
- females > males
- use of vasopressors and length of surgery can increase risk
why PONV?
- dehydrated
- opioid use in the OR (reduce the use)
- contipation
- J-J anastamosis obstructions
- aggressive with fluids and texture in teh beginngin
Preop Treatement
- early ambulation and hydration education is key
- allow pt. to drink water up to 4 hours before OR
Postoptreatment
- ondansetron (at the end of case can be given)
- aprepitant (can be taken before case)
- scoplalamine (patch can be placed on arrival)
- give adequate hydration (5-7 mL/kg of ideal bw/hr)
- early ambulation
- limiti opiod use
- call them and check up
VTE risk with Bariatric Surgery
1 complication of surgery is a clot
Risks
- lower OR time
- age
- prioe hx. of
- transfusion
- BMI increased
- open or revisted surgery
Prevention methods
- chemoprophylaxis: lovanox/LMWH and hospital protocol
- leg devices
- early ambulation is #1 thing
Bleeding Risk with bariatric Surgery
can be intralumenal or intraperitoneal
goals
- stabilize pt.
- resusitate
- transfuse
- localized bleed
A Leak in Bariatric Surgery Post -Op
when
symptoms
scans (diagnosis)
When
- within 30 days of OR
- anatomotic or staple line leak can occur: a main cause of mortality withint 30 days
- get a CT if you have any sus.
Symptoms
- fever, leukocytosis, hypotension, tachypnea, postop tachycardia
- if tachycardia > 120 and tacypnea = most sensitve for a GI leak
Diagnosis
STABLE pt = work it up
- with CT scan; with and without contrast
- UGI
UNSTABLE pt
- back to the OR
- establish feeding access (J tube or G tube)
- endoscopic intervention inf possibel
