Bariatric Surgery Flashcards
Bariatric Surgery:
- indications
- CI
BMI greater than 40kg/m2 without comorbidites
35-39.9kg/m2 w/ comorbidity:
- T2DM
- OSA
- HTN
- Hyperlipidemia
- Obesity-hypoventilation syndrome
- Pickwickian syndrom
- Non-alcoholic steatohepatitis
- pseudotumor cerebri
- GERD
- Venous stasis dz
- severe urinary incontinence
- debilitation arthritis
BMI 30-34.9kg/m2 w/ comorbidities
- uncontrolled T2DM
- metabolic syndrome
CI:
- hx of bulemia
- greater than 65YO or less than 18YO
- if you’re just doing it for lipid or glycemic control without obesity
- for CV risk reduction
- untreated major depression or psychosis
- binge eating disorders
- current drug/alcohol abuse
- severe cardiac dz w/ anesthetic risk
- severe coagulopathy
- inability to comply with requirements & dietary changes
Pre-operative Assessment
- psychological
- medical
- anesthetic risk
Psychological: look at behaviors, emotional, life situations, expectations.
- can the pt able and williing to makke necessary changes?
- identify mental disorders
- SHx in regards to previous wt loss attempts
- does the pt have the cognitive ability to do this and the support to carry it through>|?
Medical:
-complete H&P
Contemporary Bariatric Surgial Procedures:
- mechanisms of weight loss with surgery?
- MOA of each surgical mechanism
- what are the surgical procedures of each mechanism?
Mechanisms: restriction, malabsorptiion, both
MOA::
- restrictive: limit caloric intake by reducing the stomachs capacity
- malabsorptive: decrease the effectiveness of nutrient absorption by shortening the length of the functional small intestine.
Restrictive surgical procedures:
- Resection, bypass, proximal gastric outlet
- vertical banded gastroplasty
- laparoscopic adjustable gastric banding
- sleeve gastrectomy
Malabsorptive Surgical procedures:
- jejunoileal bypass
- duodenal switch operation
Combo Restrictive/Malabsorptive Surgical Procedures:
- Roux-en Y gastric bypass (MC)
- biliopancreatic diversion
- bilopancreatic diversion with duodenal switch
What are the 3 MC bariatric surgeries?
- Roux-en-Y gastric bypass
- Sleeve Gastrectomy
- Laparoscopic adjustable gastric band
Roux-en-Y Gastric Bypass:
- how much does the gastric pouch hold?
- describe procedure
- weight loss mechanism
- expected weight loss
holds less than 30ml
Procedure:
- create smaller stomach, attach jejunum to new smaller stomach thereby bypasses duodenum.
- old duodenum anastomosed into jejunum further down the GI tract so you still have functional use of gallbladder.
Weight loss mechanism:
- small pouch is restrictive
- malabsorption b/c of the “removed” small bowel
- Ghrelin inhibition (supresses appetite)
- GLP-1 and CCK increased post bypass (these suppress apetite)
Expected weight loss: up to 70% of extra weight in 2 years.
Sleeve Gastrectomy:
- describe procedure
- weight loss mechanism
- expected weight loss
Procedure:
-most of the greater curvature of the stomach is removed.
Weight loss mechanism:
- restrictive
- alterations in gastric motility
- decreased ghrelin levels
- increased GLP-1 and PYY (promote less hunger)
expected weight loss: 60% of excess weight loss in 2 years
Laparoscopic adjustable gastric band surgery:
- describe procedure
- weight loss mechanism
- expected weight loss
- post surgical diet
Procedure:
-soft silicone ring connected to an infusion port placed in the subQ tissue. Ring is inflated with saline to cause variable degrees of restriction.
Mechanism:
-purely restrictive
Expected weight loss is 50-60% of excess weight loss at 2 years
Diet:
-usually have a liquid diet that progresses to soft then full diet over a period of weeks to months
Post Surgical Monitoring:
- weight
- BP
- glycemic control
- nutritional deficiencies
- medication management
Weight and BP follow up at every visit (q4-6wks for first 6 mo)
Glycemic control: -400-800kcal diet/day for first month
- DM remission can occur in 1st month but in 1/3 pts it recurs at 5 years
- you basically have to start over with Rx.
- surgery will help with DM, it will not cure DM
Nutritional:
- macronutrient needs:
- -proteins**, carbs, and fats
- RYGB does NOT cause signifcant macronutrient deficiencies
- Micronutrients:
- -lap band = folate deficiency
- -sleeve gastrectomy = B12
- -RYGB = Vit A, D, E, K, B1, B12, iron, Copper, Zinc, folic acid, biotin, selenium
medication management:
- change meds from delayed release to immediate release
- DC oral antidiabetic meds and use insulin therapy for glycemic control
- DC antireflux meds except after sleeve gastrectomy; reflux sx increase.
- PO contraceptive pills may be less effective
- Avoid NSAIDS!!!
- -esp in Roux-en-Y
Late Complications of Bariatric Surgery
Cholelithiasis
Nutritional deficiencies
Neurological complications
Psychological complications
Which complication may present with these sx?
- upper abd pain
- hiccups
- LUQ tympany to percussion
- shoulder pain
- abd distention
- tachycardia
- SOB
- large gastric bubble on xray
Gastric remnant distention; gastric pouch is severely distended,
Which complication may present with these sx?
- several weeks post op
- N/V
- dysphagia
- GE reflux
- inability to tolerate oral intake
Stomal stenosis; narrowing at the anastomosis (pouch to Roux limb)
Marginal Ulcers
- occur where?
- cause
- Sx
- dx
- tx
Occurs: near the gastrojejunostomy
Cuase:
- poor tissue perfusion
- excess acid
- NSAIDS
- H. pylori*
- smoking
Sx:
-nausea, pain, bleeding and or perforation
Dx:
upper endoscopy
Tx:
- acid suppression
- sucralfate
- DC NSAIDS and smoking
- test andd tx H pylori
Which complication may present with these sx?
- RUQ pain
- R shoulder pain
- N/v
- fever
- pain worse with inspiration
- pain lasting longer than 6 hrs and start post eating
- tender RUQ
Acute cholecysitis/cholelithiasis
Short Bowel Syndrome:
-results in what deficiency?
results iin severe micro and macronutrient deficiences.
Which complication may present with these sx?
-15min after eating development of colicky abd pain, diarrhea, nausea, tachcardia?
early dumping; prominent post ingestion of simple carbs.
late dumping would occur 2-3hrs after a meal; dizziness, fatigue, diaphoresis, and weakness.
**Both late and early dumping are associated with high carb intake.
hyperglycemic d/t increased carbs but then become hypoglycemic from over-reaction.
