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Bariatric Surgery Flashcards

1
Q

Indications for Bariatric Surgery

A

BMI > 40 without comorbidities
BMI 35-39.9 with comorbities
BMI 30-34.9 with uncontrolled type 2 DM or metabolic syndrome

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2
Q

Comorbidities with a BMI 35-39.9 for Bariatric Surgery

A 
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
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3
Q

Contraindications for Bariatric Surgery

A

Hx of bulimia

Age >65 or

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4
Q

Preoperative Assessment for Bariatric Surgery

A

Psychological

Medical anesthetic risk

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5
Q

Preoperative Assessment for Bariatric Surgery

A 
Nutritionist
Medical bariatric specialist
Psychologist/Psychiatrist
Clinical nurse specialist
Surgeon
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6
Q

Components of the Psychological Assessment

A

Behavioral
Cognitive/emotional
Current life situation
Expectations

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7
Q

Mechanisms of Weight Loss with Surgery

A

Restriction
Malabsorption
Both

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8
Q

Define Restrictive Surgery

A

Limit caloric intake by reducing the stomach’s capacity via resection, bypass, or creation of a proximal gastric outlet

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9
Q

Examples of Restrictive Surgeries

A

Vertical banded gastroplasty
Laparoscopic adjustable gastric banding
Sleeve gastrectomy

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10
Q

Examples of Malabsorptive Surgeries

A

Jejunoileal bypass

Duodenal switch operation

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11
Q

Define Malabsorption Surgeries

A

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

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12
Q

Examples of Combination Surgeries

A

Roux-en-Y gastric bypass
Biliopancreatic diversion
Biliopancreatic diversion with duodenal switch

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13
Q

Top 3 Bariatric Surgeries

A

Roux-en-Y
Sleeve gastretomy
Laparoscopic adjustable gastric band

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14
Q

Roux-en-Y Surgery

A

Gastric pouch

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15
Q

Roux-en-Y Weight Loss Mechanism

A 
Pouch restrictive
Malabsorption of "removed" small bowel
Gastrojejunostomy can result in dumping syndrome
Ghrelin inhibition
GLP-1 & CCK increased post bypass
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16
Q

Symptoms of Dumping Syndrome

A 
Lightheadedness
Nausea
Diaphoresis
Abdominal pain
Diarrhea
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17
Q

What does insulin do?

A

Stimulates insulin synthesis

Suppresses appetite

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18
Q

What does CCK do?

A

Gallbladder contraction
Stimulates gastric emptying
Suppresses appetite

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19
Q

Expected Weight Loss with RYGB

A

Up to 70% in 2 years

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20
Q

Sleeve Gastrectomy

A

Great curvature of stomach is removed
Safer & technically less difficult that RYGM
Resistant to stretching

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21
Q

Weight Loss Mechanism of a Sleeve Gastrectomy

A

Restrictive
Alterations in gastric motility
Decreased gherkin levels
Increased GLP-1 & PYY

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22
Q

Expected Weight Loss for a Sleeve Gastrectomy

A

60% weight lost in 2 years

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23
Q

Lap Band

A

Soft silicone ring connected to infusion port

Ring inflated with saline to vary the restriction

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24
Q

Goal of Lap Band Adjustments

A

Allow a cup of dried food

Satiety for 1.5-2 hours

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25
Q

Weight Loss Mechanism for lap Band

A

Restrictive

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26
Q

Expected Weight Loss with Lap Band

A

50-60% at 2 years

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27
Q

What do you need to monitor post bariatric surgery?

A

Weight
Blood pressure
Glycemic control
Nutrient deficiencies

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28
Q

Weight & Blood Pressure Monitoring

A 
Every visit
Watch for hypotension
Check every 4-6 weeks for 6 months
Check at 9 & 12 months
Check annually
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29
Q

Macronutrient Needs

A

Protein
Carbs
Fats
RYGB doesn’t cause significant macronutrient deficiencies

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30
Q

Micronutrient Deficiency in a Lap Band Procedure

A

Folate deficiency

31
Q

Micronutrient Deficiency in a Sleeve Gastrectomy

A

B12

32
Q

Micronutrient Deficiency in a RYGB

A

Vitamin A, D, E, K, B1, B12
Iron, copper, zinc
Folic acid, biotin, selenium

33
Q

Routine Labs for Bariatric Surgery

A 
CBC
CMP
Iron studies, ferritin
B12
Lipids
Vit. D, PTH
Thiamine
Folate
Zinc
Copper
34
Q

Medication Management Post Surgery

A

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

35
Q

Factors that Affect Glycemic Control

A

400-800 kcal diet/day for 1st month
Improvement in DM control
DM remission can occur
Exposure of jejunum to undigested nutrients

36
Q

Late Complications

A

Cholelithiasis
Nutritional deficiencies
Neurologic complications
Psychological complications

37
Q

Complications of RYGB

A 
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
38
Q

Signs/Symptoms Gastric Remnant Distention

A 
Upper abdominal pain
Hiccups
LUQ tympany to percussion
Shoulder pain
Abdominal distention
Tachycardia
Shortness of breath
Large gastric bubble on Xray
39
Q

Define Gastric Remnant Distention

A

Gastric pouch severe distention secondary to mechanical obstruction or paralytic ileus

40
Q

Treatment of Gastric Remnant Distention

A

Emergency surgery

41
Q

Signs/Symptoms of Stomal Stenosis

A

N/V
Dysphagia
GE reflux
inability to tolerate oral intake

42
Q

Define Stomal Stenosis

A

Narrowing at the anastomosis

43
Q

Work-up for Stomal Stenosis

A

Endoscopy or UGI series

44
Q

Treatment of Stomal Stenosis

A

Endoscopic balloon dilation

45
Q

Define Marginal Ulcers

A

Acid injury to the jejunum or associated with gastrogastric fistula

46
Q

Causes of Marginal Ulcers

A 
Poor tissue perfusion
Excess acid
NSAIDs
H. pylori
Smoking
47
Q

Symptoms of Marginal Ulcers

A

Nausea
Pain
Bleeding and/or perforation

48
Q

Diagnostics of Marginal Ulcers

A

Upper endoscopy

49
Q

Treatment of Marginal Ulcers

A 
Acid suppression
Sucralfate
DC NSAIDs
DC smoking
Test & treat H. pylori
50
Q

Signs/Symptoms of Acute Cholecystitis/ Cholelithiasis

A 
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
51
Q

How can acute cholecystitis/ cholelithiasis be prevented?

A

Post operative ursodiol

52
Q

Diagnostics of Acut Cholecystitis/ Cholelithiasis

A

US

53
Q

Treatment of Acute CHolecystitis/ Cholelithiasis

A

Cholectomy

54
Q

What does short bowel syndrome result in?

A

Severe micro and macronutrient deficiencies

55
Q

Treatment of severe cases of short bowel syndrome

A

Intestinal transplantation

56
Q

Signs/Symptoms of Short Bowel Syndrome

A 
15 minutes postprandial:
Colicky abdominal pain
Diarrhea
Nausea
Tachycardia
57
Q

When is early dumping syndrome prominent?

A

Post ingestion of simple carbs

58
Q

Symptoms of Late Dumping Syndrome

A

Dizziness
Fatigue
Diaphoresis
Weakness

59
Q

Symptoms of Severe Hypoglycemia

A

Blackouts

Seizures

60
Q

What can sever hypoglycemia be secondary to post bariatric surgery?

A

Insulinoma

Islet cell hypertrophy

61
Q

Bowel changes post RYGB

A

Diarrhea

Loose stools

62
Q

Bowel changes post gastric banding

A

Constipation

63
Q

What can be occurring when a patient complaint is “I’m not losing weight” or “I’m gaining weight” after bariatric surgery?

A

Maladaptive eating patterns
Gastrogastric fistula
Gradual enlargement of the gastric pouch
Dilation of the gastrojejunal anastomosis

64
Q

Complications from Gastric Banding

A 
Pouch dilation
Stomal obstruction
Band slippage, infection or erosion
Incisional hernias
Port-tubing disconnections
Port infections
Esophagitis
Esophageal dilation
65
Q

Symptoms of Stomal Obstruction

A

Persistent nausea
Vomiting
Inability to tolerate secretions or oral intake

66
Q

What can stomal obstruction be secondary to?

A

Edema

Band being too tight

67
Q

Diagnostic of Stomal Obstruction

A

UGI

68
Q

Treatment of Stomal Obstruction

A

NG tube to decompress until edema subsides or surgery for band revision

69
Q

Symptoms for Band Erosion

A 
Infection
Failure of weight loss
N/V
Epigastric pain
Hematemesis
70
Q

Diagnostic of Band Erosion

A

Endoscopy

71
Q

Treatment of Band Erosion

A

Surgical removal

72
Q

Most Common Sleeve Gastrectomy Complications

A

GERD
Bleeding
tenses of the stoma
Leaks

73
Q

What local factors impede gastric leaks from healing?

A

Inadequate blood supply at staple line
Gastric-wall heat ischemia
High intra-gastric pressure

GI (20 decks)

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