Bariatric Surgery Flashcards
Indications for Bariatric Surgery
BMI > 40 without comorbidities
BMI 35-39.9 with comorbities
BMI 30-34.9 with uncontrolled type 2 DM or metabolic syndrome
Comorbidities with a BMI 35-39.9 for Bariatric Surgery
DM2 OSA HTN Hyperlipidemia Obesity-hypoventilation syndrome (OHS) Pickwickian syndrome (OSA+OHS) Nonalcoholic steatohepatitis (NASH) Pseudotumor cerebri GERD Venous stasis disease Severe urinary incontinence Debilitating arthritis Impaired QOL
Contraindications for Bariatric Surgery
Hx of bulimia
Age >65 or
Preoperative Assessment for Bariatric Surgery
Psychological
Medical anesthetic risk
Preoperative Assessment for Bariatric Surgery
Nutritionist Medical bariatric specialist Psychologist/Psychiatrist Clinical nurse specialist Surgeon
Components of the Psychological Assessment
Behavioral
Cognitive/emotional
Current life situation
Expectations
Mechanisms of Weight Loss with Surgery
Restriction
Malabsorption
Both
Define Restrictive Surgery
Limit caloric intake by reducing the stomach’s capacity via resection, bypass, or creation of a proximal gastric outlet
Examples of Restrictive Surgeries
Vertical banded gastroplasty
Laparoscopic adjustable gastric banding
Sleeve gastrectomy
Examples of Malabsorptive Surgeries
Jejunoileal bypass
Duodenal switch operation
Define Malabsorption Surgeries
Decrease the effectiveness of nutrient absorption by shortening the length of the functional small intestine by bypassing of the small bowel absorptive surface area or diversion of the biliopancreatic secretions that facilitate absorption
Examples of Combination Surgeries
Roux-en-Y gastric bypass
Biliopancreatic diversion
Biliopancreatic diversion with duodenal switch
Top 3 Bariatric Surgeries
Roux-en-Y
Sleeve gastretomy
Laparoscopic adjustable gastric band
Roux-en-Y Surgery
Gastric pouch
Roux-en-Y Weight Loss Mechanism
Pouch restrictive Malabsorption of "removed" small bowel Gastrojejunostomy can result in dumping syndrome Ghrelin inhibition GLP-1 & CCK increased post bypass
Symptoms of Dumping Syndrome
Lightheadedness Nausea Diaphoresis Abdominal pain Diarrhea
What does insulin do?
Stimulates insulin synthesis
Suppresses appetite
What does CCK do?
Gallbladder contraction
Stimulates gastric emptying
Suppresses appetite
Expected Weight Loss with RYGB
Up to 70% in 2 years
Sleeve Gastrectomy
Great curvature of stomach is removed
Safer & technically less difficult that RYGM
Resistant to stretching
Weight Loss Mechanism of a Sleeve Gastrectomy
Restrictive
Alterations in gastric motility
Decreased gherkin levels
Increased GLP-1 & PYY
Expected Weight Loss for a Sleeve Gastrectomy
60% weight lost in 2 years
Lap Band
Soft silicone ring connected to infusion port
Ring inflated with saline to vary the restriction
Goal of Lap Band Adjustments
Allow a cup of dried food
Satiety for 1.5-2 hours
Weight Loss Mechanism for lap Band
Restrictive
Expected Weight Loss with Lap Band
50-60% at 2 years
What do you need to monitor post bariatric surgery?
Weight
Blood pressure
Glycemic control
Nutrient deficiencies
Weight & Blood Pressure Monitoring
Every visit Watch for hypotension Check every 4-6 weeks for 6 months Check at 9 & 12 months Check annually
Macronutrient Needs
Protein
Carbs
Fats
RYGB doesn’t cause significant macronutrient deficiencies
Micronutrient Deficiency in a Lap Band Procedure
Folate deficiency
Micronutrient Deficiency in a Sleeve Gastrectomy
B12
Micronutrient Deficiency in a RYGB
Vitamin A, D, E, K, B1, B12
Iron, copper, zinc
Folic acid, biotin, selenium
Routine Labs for Bariatric Surgery
CBC CMP Iron studies, ferritin B12 Lipids Vit. D, PTH Thiamine Folate Zinc Copper
Medication Management Post Surgery
Change from delayed release to immediate release
DC DM meds & use insulin for glycemic control
DC antireflex meds except after sleeve gastrectomy
Contraceptive pills less effective
Avoid NSAIDs
Factors that Affect Glycemic Control
400-800 kcal diet/day for 1st month
Improvement in DM control
DM remission can occur
Exposure of jejunum to undigested nutrients
Late Complications
Cholelithiasis
Nutritional deficiencies
Neurologic complications
Psychological complications
Complications of RYGB
Gastric remnant distention Stomal stenosis Internal hernias Short bowel syndrome Metabolic/nutritional derangements Renal failure Post-op hypoglycemia Change in bowel habits Failure to lose weight & weight regain Ventral incisional hernias
Signs/Symptoms Gastric Remnant Distention
Upper abdominal pain Hiccups LUQ tympany to percussion Shoulder pain Abdominal distention Tachycardia Shortness of breath Large gastric bubble on Xray
Define Gastric Remnant Distention
Gastric pouch severe distention secondary to mechanical obstruction or paralytic ileus
Treatment of Gastric Remnant Distention
Emergency surgery
Signs/Symptoms of Stomal Stenosis
N/V
Dysphagia
GE reflux
inability to tolerate oral intake
Define Stomal Stenosis
Narrowing at the anastomosis
Work-up for Stomal Stenosis
Endoscopy or UGI series
Treatment of Stomal Stenosis
Endoscopic balloon dilation
Define Marginal Ulcers
Acid injury to the jejunum or associated with gastrogastric fistula
Causes of Marginal Ulcers
Poor tissue perfusion Excess acid NSAIDs H. pylori Smoking
Symptoms of Marginal Ulcers
Nausea
Pain
Bleeding and/or perforation
Diagnostics of Marginal Ulcers
Upper endoscopy
Treatment of Marginal Ulcers
Acid suppression Sucralfate DC NSAIDs DC smoking Test & treat H. pylori
Signs/Symptoms of Acute Cholecystitis/ Cholelithiasis
RUQ pain R. shoulder pain/ pain in upper back N/V Fever Worse pain with inspiration Pain last longer than 6 hours Pain starts postprandial Tender RUQ on exam
How can acute cholecystitis/ cholelithiasis be prevented?
Post operative ursodiol
Diagnostics of Acut Cholecystitis/ Cholelithiasis
US
Treatment of Acute CHolecystitis/ Cholelithiasis
Cholectomy
What does short bowel syndrome result in?
Severe micro and macronutrient deficiencies
Treatment of severe cases of short bowel syndrome
Intestinal transplantation
Signs/Symptoms of Short Bowel Syndrome
15 minutes postprandial: Colicky abdominal pain Diarrhea Nausea Tachycardia
When is early dumping syndrome prominent?
Post ingestion of simple carbs
Symptoms of Late Dumping Syndrome
Dizziness
Fatigue
Diaphoresis
Weakness
Symptoms of Severe Hypoglycemia
Blackouts
Seizures
What can sever hypoglycemia be secondary to post bariatric surgery?
Insulinoma
Islet cell hypertrophy
Bowel changes post RYGB
Diarrhea
Loose stools
Bowel changes post gastric banding
Constipation
What can be occurring when a patient complaint is “I’m not losing weight” or “I’m gaining weight” after bariatric surgery?
Maladaptive eating patterns
Gastrogastric fistula
Gradual enlargement of the gastric pouch
Dilation of the gastrojejunal anastomosis
Complications from Gastric Banding
Pouch dilation Stomal obstruction Band slippage, infection or erosion Incisional hernias Port-tubing disconnections Port infections Esophagitis Esophageal dilation
Symptoms of Stomal Obstruction
Persistent nausea
Vomiting
Inability to tolerate secretions or oral intake
What can stomal obstruction be secondary to?
Edema
Band being too tight
Diagnostic of Stomal Obstruction
UGI
Treatment of Stomal Obstruction
NG tube to decompress until edema subsides or surgery for band revision
Symptoms for Band Erosion
Infection Failure of weight loss N/V Epigastric pain Hematemesis
Diagnostic of Band Erosion
Endoscopy
Treatment of Band Erosion
Surgical removal
Most Common Sleeve Gastrectomy Complications
GERD
Bleeding
tenses of the stoma
Leaks
What local factors impede gastric leaks from healing?
Inadequate blood supply at staple line
Gastric-wall heat ischemia
High intra-gastric pressure
