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Bariatric surgery Flashcards

1
Q

Indications for bariatric surgery?

A
  • BMI of 40 kg/m2 or greater w/o comorbidities
  • BMI of 35-39.9 with comorbidity: DM 2, OSA, HTN, hyperlipidemia, obesity hypoventilation syndrome, pickwickian syndrome (OSA+OHS), nonalcoholic steatohepatitis, pseudotumor cerebri, GERD, venous stasis disease, severe urinary incontinence, debiliation arthritis, impaired quality of life
  • BMI of 30-34.9 and uncontrollable DM 2, metabolic syndrome (lack of evidence to support long term benefit in this group)
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2
Q

CIs to bariatric surgery?

A
  • hx of bulimia
  • over 65 and under 18 (some exceptions made for under 18)
  • for lipid and glycemic control
  • for CV risk reduction
  • untx major depression or psychosis
  • binge-eating disorders
  • current drug or ETOH abuse
  • severe cardiac disease with prohibitive anesthetic risks
  • severe coagulopathy
  • inability to comply with requirements including (life long nutritional supplements) and dietary changes
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3
Q

Preop assessment includes? Who is involved?

A
  • psych
  • medical
  • anesthetic risk
  • team approach: nutritionist, medical bari specialist, psychologist/psychiatrist, clinical nurse specialist, surgeon
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4
Q

Goals and components for psych assessment?

A
  • is pt able and willing to make necessary changes?
  • ID of mental disorders
  • social hx in regards to previous wt loss attempts, physical activity, substance abuse, compulsive eating
  • does pt hav cognitive ability to do this and the support to carry it through?
  • Components: behavioral, cognitive/emotional, current life situation, expectations
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5
Q

Medical assessment for preop?

A
  • complete H&P
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6
Q

mechanisms of wt loss with surgery?

A
  • restrictive
  • malabsorptive
  • both
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7
Q

How do restrictive surgeries work?

A
  • limit caloric intake by reducing stomach’s capacity:
    resection
    bypass
    creation of proximal gastric outlet
 surgeries:
-vertical banded gastroplasty 
(not that common anymore)
-laparoscopic adjustable gastric banding
- sleeve gastrectomy
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8
Q

Malabsorptive surgeries available? How do these work?

A
  • jejunoileal bypass
  • duodenal switch operation
  • decrease the effectiveness of nutrient absorption by shortening length of fxnl smal intestine:
    bypass small bowel absorptive surface area, diversion of biliopancreatic secretions that faciliate absorption
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9
Q

Combo restrictive/malabsorptive surgeries?

A
  • Roux-en-Y gastric bypass (RYGB) - most common
  • biliopancreatic diversion
  • bilipancreatic diversion with duodenal switch
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10
Q

3 most common bari surgeries?

A
  • RYGB - 47%
  • sleeve gastrectomy - 28%
  • laparoscopic adjustable gastric band - 18%
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11
Q

What is the RYGB surgery? How common is it?

A
  • create small gastric pouch (less than 30 ml) and an anastomosis to a roux limb of the jejunum that bypasses 75-150 cm of small bowel - restricts food and limits absorption
  • major digestion and absorption of nutrients occurs in common channel where pancreatic enzymes and bile mix
  • most commonly performed bari surgery in the US
  • 47% of wt loss surgeries done in 2011
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12
Q

How does RYGB promote wt loss?

A
  • small pouch is restrictive
  • malabsorption b/c of removed small bowel
  • gastrojejunostomy can result in dumping syndrome with high sugar meals - lightheadedness, nausea, diaphoresis and/or abdominal pain, and diarrhea
  • ghrelin inhibition (suppresses appetite)
  • GLP-1 and CCK increased post bypass (may promote an anorectic state)
  • CCK stimulates gastric emptying and appetite suppression
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13
Q

What is the expected wt loss with RYGB?

A
  • up to 70% of extra wt in 2 yrs
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14
Q

What is sleeve gastrectomy? How common is it?

A
  • majority of greater curvature of the stomach is removed and a tubular stomach is created. It has a small capacity and is resistant to stretching due to absence of the fundus and has few ghrelin producing cells
  • 2nd most common wt loss surgery performed worldwide
  • 28% of all procedures in 2011
  • safer and technically less difficult to perfrom than RYGB
  • new stomach is resistant to stretching w/o the fundus
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15
Q

Wt loss mechanism of sleeve gastrectomy?

A
  • restrictive
  • alterations in gastric motility - slow transit time since fundus is removed
  • decreased ghrelin levels
  • increased GLP-1 and PYY (promotes less hunger)
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16
Q

Expected wt loss from sleeve gastrectomy?

A
  • 60% of excess wt lost in 2 yrs
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17
Q

Laparoscopic adjustable gastric band surgery - how common, and what is it? How safe is this?

A
  • 18% of bari surgeries done in 2011
  • soft silicone ring connected to an infusion port placed in subq tissue
  • ring is inflated with saline to cause variable degrees of restriction
  • goal of band adjustments: allow a cup of dried food, satiety for at least 1.5-2 hrs after a meal
  • lowest mortality rate among bariatric surgeries
  • replaced the earlier procedure vertical banded gastroplasty that had higher incidence of complications
  • band is adjustable to allow more food and liquids in the future if needed
  • Purely restrictive wt loss mechanism
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18
Q

Expected wt loss from lap band?

A
  • 50-60% of excess wt lost at 2 yrs
19
Q

What bari surgery is recommended for diabetes pts?

A
  • gastric bypass - change in hormones, more favorable outcome
20
Q

Post surgical diet?

A
  • varies depending on procedure

- usually have a liquid diet that progresses to soft then full diet over a period of weeks to months

21
Q

wt and BP monitoring post procedure?

A
  • monitor both at q f/u
  • watch for hypotension (esp if persistent vomiting)
  • check BP and wt q 4-6 wks for the first 6 months then at 9 and 12 for month, and then annually
22
Q

impt macronutrient needs for postop?

A
  • protein is super impt, carbs and fats
  • same among diff procedures
  • RYGB doesn’t cause sig macronutrient deficiences
23
Q

impt micronutrients to supplement postop?

A
  • lap band: folate deficiences (can’t eat as many veggies)
  • sleeve gastrectomy: B12 (removing parietal cells in fundus - IF)
  • RYGB: Vit A, D, E, K, B1 (thiamine), B12, iron, copper, zinc, folic acid, biotin, selenium
24
Q

What labs should be checked at 3, 6, 12 months and then annually?

A
  • CBC
  • CMP
  • iron studies, ferritin
  • B12
  • lipids
  • 25 OH-Vit D, PTH
  • thiamine
  • folate
  • zinc
  • copper
25
Q

Med management post surgery?

A
  • change meds from delayed release to immediate release - crush or liquid form
  • in general should DC oral antidiabetic meds and use insulin therapy for glycemic control
  • usually can DC antireflux meds except after sleeve gastrectomy reflux sxs increase
  • OCPs may be less effective
  • in general avoid NSAIDs - esp in pts who have had RYGB, they have very little stomach area and are set up for ulcers
26
Q

What factors affect glycemic control post surgery?

A
  • 400-800 kcal diet/day for 1st month
  • avg wt loss in first month is 20-40 lbs
  • improvement in DM control happens regardless of amt of wt lost
  • DM remission can occur in first month - but in 1/3 of pts recurs at 5 yr mark
  • exposure of distal jejunum to undigested nutrients - increased peptide YY, GLP-1, and GIP
27
Q

Late complications of bari surgery (post 30 days)?

A
  • cholelithiasis (most common in pts who have lost a lot of wt)
  • nutritional deficiencies
  • neuro complications
  • psych complications
28
Q

Complications of RYGB?

A
  • gastric remnant distension
  • stomal stenosis
  • internal hernias
  • short bowel syndrome
  • dumping syndrome
  • metabolic/nutritional derangements
  • renal failure
  • post-op hypoglycemia
  • change in bowel habits
  • failure to lose wt and wt regain
  • ventral incisional hernias
29
Q 
What complication would present with these sxs:
upper abdominal pain
hiccups
LUQ tympany
shoulder pain
abdominal distension
tachycardia
SOB
large gastric bubble on xray
  • how common is this? How severe?
A

gastric remnant distenstion

  • rare
  • may be fatal
  • gastric pouch severe distension secondary to mechanical obstruction or paralytic ileus
  • progressive distension and rupture
  • tx: emergent surgery
  • RYGB complication
30
Q 
Which complication may present with these sxs:
several weeks post op -
N/V
dysphagia
GE reflux
inability to tolerate oral intake

workup and tx?

A

stomal stenosis: upper problem - either before or after gastric pouch

  • 6-20% of pts
  • narrowing at anstomosis (pouch to rouch limb)
  • work up: endoscopy or UGI series
  • tx: endoscopic balloon dilation
  • RYGB complication
31
Q

What are marginal ulcers? Where do they occur, What are the causes?

A
  • acid injury to the jejunum or assoc with gastrogastric fistula
  • occur near gastrojejunostomy
  • may present with nausea, pain, upper GI bleed
  • 0.6-16% of pts
  • causes:
    poor tissue perfusion (sutures too tight, didn’t heal right)
    excess acid
    NSAIDs
    H. pylori
    smoking
  • RYGB complication
32
Q

Sxs, dx and tx of marginal ulcers?

A
  • sxs: Nausea, pain, bleeding, and/or perforation
  • dx: upper endoscopy
  • tx:
    acid suppression
    sucralfate
    DC NSAIDs
    DC smoking
    test and tx H pylori
33
Q 
What complication would present with these sxs:
RUQ pain
R shoulder pain or pain in R upper back
N/V
fever
pain may worsen with deep inspiration
pain may last longer then 6 hrs and start postprandia
tender RUQ on exam

Dx, TX?

A
  • acute cholecystitis/cholelithiasis
  • 38% of pts within 6 months of surgery
  • can be prevented by post op ursodiol
  • dx: US
  • Tx: surgical removal of gallbladder
34
Q

Pt presents with abdominal pain following RYGB, and on CT scan - swirled appearance of mesenteric vessels with mesenteric edema, most likely cause?

A
  • short bowel syndrome: hernia through mesentery which leads to obstruction of vessels
  • results in severe micro and macronutrient deficiencies
  • in severe cases may reqr intestinal transplantation
35
Q

What complication presents with these sxs:

15 min postprandial - development of colicky abdominal pain, diarrhea, nausea and tachycardia

A
  • early dmping syndrome
  • up to 50% of pts develop either early or late dumping syndrome
  • prominent post ingestion of simple carbs
  • quick spike in blood sugar triggers this, main sx: is immediate diarrhea
36
Q

When does late dumping syndrome occur? Sxs?

A
  • 2-3 hrs after a meal
  • dizziness, fatigue
  • diaphoresis and weakness
37
Q

What complication would a pt have if they complain of having blackouts and seizures?

A
    • severe hypoglycemia
  • may be secondary to insulinoma
  • may be secondary to iselt cell hypertrophy
  • slowing food transit time may resolve the sxs (acarbose)
38
Q

What bowel habit changes are common post surgery?

A
  • diarrhea or loose stools are common post RYGB

- constipation is common post gastric banding

39
Q

What may be wrong if the pt complains about not losing wt, or complains of gaining wt?

A
  • maladaptive eating patterns
  • gastrogastric fistula
  • gradual enlargement of gastric pouch
  • dilation of gastrojejunal anastomosis
40
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
41
Q

What would these sxs indicate: persistent nausea, vomiting and inability to tolerate secretions or oral intake

  • how common is this, Dx, tx?
A
  • stomal obstruction
  • up to 14%
  • can be acute (shortly after surgery)
  • may be secondary to edema or due to band being too tight
    dx: UGI
    tx: NG tube to decompress until edema subsides or surgery for band revision (risk is esophageal perf if tissue is necrotic)
42
Q

What complication is this:

infection, failure of wt loss, N/V, epigastric pain, hematemesis? How common is this, dx, Tx?

A
  • band erosion
  • up to 7%
  • occurs at mean of 22 months
  • dx: endoscopy
  • tx: surgical removal
43
Q

Most common sleeve gastrectomy complications?

A
  • GERD
  • bleeding
  • stenosis of stoma
  • leaks
44
Q

Most serious complication of SG? Usually do to?

A
  • gastric leaks
  • occurs in up to 5.3% of pts
  • leaks usually due to local factors that impede healing:
    inadeq blood supply to staple line, gastric wall heat ischemia - too much cautery done
    there can be high intragastric pressure - over-eating

GI (21 decks)

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