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.
Which complication may present with these sx?
- blackouts
- seizures
severe hypoglycemia; slowing food transit time may resolve the sx. (Acarbose slows gastric emptying)
What DM med slows gastric emptying?
Acarbose/precose.
Diarrhea MC in which surgical procedure? Constipation?
Diarrhea MC in RYGB and Constipation MC in gastric banding
What are some reasons that pts dont lose weight or gain weight post surgery?
maladaptive eating patterns
gastrogastric fistula
gradual enlargment of the gastric pouch
dilation of the gastrojejunal anastomosis
Which complication may present with these sx?
-persistent nausea/vomiting, inability to tolerate secretions of oral intake?
Stomal obstruction:
Which complication may present with these sx?
- infection
- failure of weight loss
- N/V
- epigastric pain
- hematemesis
Band erosion; tx is surgical removal
What are the MC sleeve gastrectomy complications?
GERD, bleeding, stenosis of stoma, leaks
*Gastric leaks d/t inadequate blood supply at the staple line, gastric wall heat ischemia, high intragastric pressure.
