Bariatric Surgery Flashcards
Criteria for patient selection for bariatric surgery
Need all four
1. BMI > 40 or > 35 with comorbidities
2. Failure of non-surgical methods of weight reduction
3. Psychological stability
4. Absence of alcohol or drug abuse
Contraindications
Smoking tobacco is a relative contraindication to surgery
Use of NSAIDS or aspirin is an absolute contraindication to RYGB
Inflammatory bowel disease is an absolute contraindication to bariatric surgery
Metabolic syndrome
Metabolic syndrome definition Waist circumference > 40 inches in men and > 35 in women, plus 2 of the following:
RY Gastric bypass
- (Restriction and malabsorption) – 2nd MC procedure performed
- Transect jejunum 30-50 cm from lig of treitz = biliopancreatic limb
- Length of roux limb is 100-150 cm long
- Better early weight loss vs banding
- Best one to choose if diabetic, has best response
- Best one to choose if patient has GERD or Barrett’s
- Only do cholecystectomy if patient has symptomatic cholelithiasis
- MC complication is nausea
- This surgery has anti-reflux properties, if has reflux or Barret’s do bypass
- Use of NSAIDS or aspirin is contraindicated with this surgery marginal ulcer
- MCC of bowel obstruction after this surgery = internal hernia = MC mesojejunal window, 2nd MC is petersen’s (Roux limb mesentery)
If patient is morbidly obese and presents with symptoms of GERD, don’t do anti-reflux surgery, go straight to gastric bypass, has anti-reflux effect
Laparoscopic Vertical Sleeve Gastrectomy
- (restriction) – MC procedure performed in US 60-70%
- Reduces Ghrelin found in fundus
- Lower risk of complications and re-operation compared with gastric bypass
- Not reversible, but can convert to RYGB or duodenal switch if want more weight loss
- Avoid this surgery if patient has acid reflux or barret’s worsens
- If patient develops medically refractory reflux after this surgery convert to RYGB or place magnetic sphincter augmentation device
Magnetic sphincter augmentation device – approved use for GERD. Magnetic beads augment LES pressure
- Laparoscopic adjustable gastric band (restriction)
- Laparoscopic adjustable gastric band (restriction) – Less than 10% of all weight loss procedures
- Reversible
- Very high rate of complications less and less being performed
- Does not provide sustained weight loss
- Gastric band is placed in a 45-degree orientation (2 o’clock and 8 o’clock position) toward left shoulder distal to GEJ
- Port in subQ can allow tightening or loosening
- Don’t fill port until 6 weeks after surgery, then fill it with increments of .5 ml, 6 X, throughout 1st year
- Infected port band erosion into stomach if found deflate the balloon then schedule for laparoscopic band removal
- Requires average of 5-6 adjustment in 1st year
- MC complication: regurgitation (productive burping) Tx eat less and more slowly
Duodenal switch with biliopancreatic diversion
(malabsorption and restrictive) – least commonly performed
- Complex surgery, many severe malabsorptive nutritional deficiencies
- Create a gastric sleeve
- Divide jejunum 250 cm proximal to ileocecal valve
- Take proximal jejunum bowel and anastomose to ileum 100 cm proximal to ileocecal valve
- Transect duodenum 3-4 cm distal to pylorus
- Anastomose Roux limb to proximal duodenum
- Roux limb = 150 cm, common channel 100 cm proximal to ileocecal valve
Jejunoileal bypass
- Anastomosing proximal 35 cm of jejunum to 10 cm proximal to ileocecal valve
- No longer performed
- Complications: cirrhosis, kidney failure, kidney stones, osteoporosis
- Need to correct all of these to RYGB if found
Pre-op, post-op (vitamins, weight loss), hernia during procedure,
Remember to start prophylactic AC on all bariatric surgery patients
If you find a hiatal hernia in any bariatric surgery intra-op you should fix it at that time
Before bariatric surgery, consult dietitian, mental health
All receive multivitamin, iron, calcium, vitamin D, vitamin B12 after surgery
Iron deficiency is the MC metabolic disorder following gastrectomy. Tx: oral iron
Calcium deficiency Ca and Vit D
Thiamine, B12, folate deficiency
B12 deficiency occurs with: Gastric bypass, terminal ileum resection, blind loop syndrome
Gastric bypass and duodenal switch have the most weight loss in 1st 2 years. Lose 70-80% of excess weight
PAD does not get better after surgery
Gastric bypass complications
Gastric bypass complications
Leak
- Peak incidence is POD 5
- Diagnose with with CT with oral contrast, it is better than UGI
- MC leak is the GJ anastomosis
- MCC of leak overall and late is ischemia. MCC early is technical
- Early leak or sick patient reop, washout, omental patch, place drains, place feeding G tube in remnant.
- Late leak – PC drain and abx
Anastomotic stenosis
- If early re-op
- Late dilation
Any SBO in these patients need an operation
Dilation of excluded remnant stomach on imaging hiccoughs, large stomach bubble risk for staple line rupture. Dx: AXR. Tx: Percutaneous G tube using US
MCC of death after RYGB PE
Bilroth II
Afferent limb (bilious limb) (toward stomach)
Efferent (carries food) (Away from stomach)
Dumping syndrome
– Occurs in RNYGB, and Billroth II
Early dumping = 1 hour
- Caused by rapid shift of osmotic gradients extracellular fluid shift
- Associated with gastrointestinal side effects abd pain, nausea, bloating, vomiting
Late dumping syndrome = 1-3 hours
- Caused by High insulin hypoglycemia increase in catecholamines (key issue causing symptoms)
- Associated with cardiovascular side effects palpitations, tachycardia, sweating, flushing
Dx: Gastric emptying study, make sure to get an UGI to rule out obstruction
Tx: 95% resolve with diet modifications = 1st step in treatment
- !!!Avoid any liquids with meals!!! = KEY
- small, high protein, high fiber, high fat, LOW CARBS
- Instruct patient to lie down after meals. Eat slowly
- If above fails octreotide (very effective)
Surgery: (very rarely needed)
Bile reflux gastritis
Bile reflux gastritis – after billroth II or pyloroplasty
Epigastric pain, with bilious emesis
Pain is not relieved with vomiting
Dx: EGD (best) bile reflux and gastritis. HIDA can also help make dx, shows reflux into stomach
Billroth II has highest incidence, next is Billroth I, then vagotomy and pyloroplasty
Tx: cholestyramine, reglan, PPI medical management usually doesn’t work
Surgery:
- convert to RYGB with long (at least 40 cm) Roux limb
- Or reconstruct Bilroth II with braun anastomosis – jejunojejunal anastomosis. (also reduces afferent loop syndrome risk)
Chronic gastric atony (roux syndrome) (delayed gastric emptying) in RNYGJ
Chronic gastric atony (roux syndrome) (delayed gastric emptying) in RNYGJ
Dx: gastric emptying study
- Need to also rule out obstruction (UGI, endoscopy)
Tx: metoclopramide or erythromycin.
Surgical: If above fails near total gastrectomy with RY
Gastroparesis dx
Gastroparesis dx: gastric emptying study > 10% of food in stomach after 4 hours
Treatment: Metoclopramide (reglan)
Blind loop syndrome
Can occur in diverticulaes, fistulas, strictures, small bowel bypass
Poor motility and stasis in afferent limb after Billroth II or RYGB
Causes bacterial overgrowth - MC E. coli
Abd pain, diarrhea, steatorrhea, B12 deficiency
Can present with deficiency of all fat-soluble vitamins ADEK
Dx: Carbohydrate breathe test!!!!! Bacteria produces excess 14C-labeled carbohydrates
Tx: Tetracycline and flagyl and b12, low fat diet
Surgery: make shorter afferent limb
Blind loop syndrome can also occur with bowel diverticulum, fistula or stricture. Don’t have to have bilroth II
- Dx with D-xylose test high CO2 confirms dx
Afferent loop syndrome! obstruction
Afferent loop syndrome! obstruction
With billroth II caused by mechanical obstruction of afferent limb (bilious limb)
One of the main causes of duodenal stump blow out
RUQ pain, nonbilious vomiting, pain is then relieved with bilious vomiting
Risk factors
- Afferent limb should be 10-15 cm
- Long afferent limb (>40 cm) with billroth II
- Antecolic gastrojejunostomy increases risk for afferent loop syndrome. However, antecolic is preferred when operating for cancer
Dx: CT scan shows dilated afferent limb, that is fluid filled, but does not fill with contrast
Tx: This is usually surgical Go to OR
Tx: Usually conversion of Billroth II to RYGJ. Other options:
- Perform Braun anastomosis (afferent to Efferent connection)
- Re-anastomose with shorter afferent limb (40 cm)
Efferent loop obstruction
Much less common than afferent
Bilious vomiting. Abdominal pain.
Dx: UGI (best)
Tx: EGD balloon dilation
Duodenal stump blow-out
Found in Billroth II or RY
Dx: CT scan (best)
TX: re-operate, wash out and place lateral duodenostomy tube, drains.
Marginal ulcers
More common in RYGJ then Billroth II
Expected weight loss after surgery:
Percentage of expected weight loss after bariatric surgery = (Weight loss kg)/(excess weight)
Excess weight = Actual weight – Ideal body weight
DVT prophylaxis for bariatric patients
Immediate BMI-based preoperative dose of low-molecular weight heparin as well as post-operative prophylaxis for 28 days
