Bariatric Surgery Flashcards
1
Q
Why is obesity and bariatric surgery recognized for federal coverage?
A
Due to it’s increased mortality from cancer
2
Q
Name 5 health implications from obesity
A
- Hypertension
- Coronary heart disease
- Type 2DM
- Gallbladder disease
- Osteoarthiritis
3
Q
What are some factors influencing obesity?
A
- Social
- Individual psychology
- Individual activity
- Food productions, foods available
- Biology
4
Q
Discuss obesity trends in Canada
A
- Has increased
- Self-reported obesity is always less reported than measured obesity
5
Q
Why do obesity rates increased with age, then sharply decline in the elderly?
A
Due to earlier death associated with obesity
6
Q
What is the economic burden of obesity in Canada?
A
4.7-7.1 billion alone
7
Q
Worldwide obesity has ____ since 1980
A
doubles
8
Q
More than ____ children <5 years were overweight in 2011
A
40 million
9
Q
What is the BMI Classification for bariatric patients?
A
BMI >/= to 35
Class II and above
10
Q
What is bariatric surgery?
A
The surgical treatment of obesity
11
Q
What is the purpose of BS? What is NOT it’s purpose?
A
- To promote significant weight loss and assist/improve weight-related comorbidities
- NOT related to lower weight for aesthetics
12
Q
Why is bariatric surgery considered “metabolic surgery”
A
As many metabolic issues, such as type II diabetes may be resolved with these surgeries
13
Q
Indications for BS?
A
1) BMI >40 is an immediate candidate
2) BMI 35-40 with significant obesity-related co-morbidities
14
Q
For patients with a BMI of 35-40, what are the significant obesity-related co-morbidites needed to qualify for BS?
A
- T2DM
- Hypertension
- NAFLD (NOT cirrhosis)
- HyperTGs
15
Q
In addition to BMI and co-morbidities, what else must candidates possess?
A
- Acceptable operative risk
- Failure of non-surgical weight-loss
- Well informed, compliant and motivated patient
16
Q
What is the failure rate of dieting? BS?
A
-95%-50%
17
Q
Contraindications to BS?
A
- Active substance use
- Uncontrolled psychiatric illness
- Cirrhosis
- Pulmonary hypertension
- Severe cardiac or respiratory disease
- Active pregnancy
18
Q
Is binge-eating a contraindication to BS?
A
No
-however, the surgery will not change or reverse an ED
19
Q
How will binge-eating change after BS?
A
-They cannot physically fit all the food into their stomach, but may consume the same amount of food over a longer period of time (grazing), and can cause weight re-gain
20
Q
What are the two restrictive procedures?
A
1) Adjustable gastric band (AGB)
2) Vertical sleeve gastrectomy (VSG)
21
Q
What are the two restrictive and malabsorptive procedures?
A
1) Roux-en-Y gastric bypass (RYGB)
2) Biliopancreatic diversion with duodenal switch (BPD/DS)
22
Q
Discriminate between restrictive and malabsorptive
A
- Restrictive refers to restricting the stomach size, allowing less food into stomach
- Malabsorption means bypassing a certain length of the SI, therefore less food in AND less food absorbed
23
Q
Discuss the AGB
A
- Reversible
- Rapid satiety
- Requires frequent adjustments
- Unknown durability of the band
24
Q
Is the AGB successful?
A
Lowest success rate, low enough to no longer be covered by the government or offered in the private sector
25
How does the AGB work?
We have a port on the outside of the body, where if we inject with saline it will feed into the band, which will expand and then restrict the stomach
26
Discuss the Sleeve gastrectomy
- Most of the fundus is removed (70-80%)
- Pyloric sphincter and intestines remain intact
- Rapid satiety
- There is no bypass of absorption
27
Is there likely to be dumping syndrome with the sleeve gastrectomy
No, the pyloric sphincter is still intact
28
Discuss Roux-en-Y gastric bypass
- New gastric pouch is created, excluding the fundus
| - Bypass of intestines, causing malabsorption
29
Discuss how RYGB alters GI architecture
- The smaller upper part of the resected stomach is attached to the top of the duodenum.
- The larger (fundus) part of the resected stomach is attached to the proximal jejunum
- There is no pyloric sphincter
30
What comprises the alimentary limb in RYGB?
- Where the food goes through
- Small resection of stomach and the duodenum
- No absorption occurs here
31
What comprises the pancreatic limb in RYBG?
- Where pancreatic and gastric enzymes reach
| - Resected larger portion of the stomach which reached the proximal jejunum at the anastomosis
32
What meets at the common channel in RYBG?
- The alimentary and pancreatic limb
| - Absorption will take place in the distal jejunum
33
Discuss the BPD/DS
- Sleeve gastrectomy and bowel resection
- The common limb is only 100 cm of the ileum
- More malabsorption than the RYGB
34
Which surgery may be done in 2 procedures?
BPD/DS
35
Discuss how BPD/DS alter the GI architecture
- The fundus is removed (similar to sleeve), no pylorus.
- Start of duodenum is resected, and attached to gallbladder and pancreas
- Other end of duodenum will be attached to resected stomach
- Common channel meets at ileum
36
What isa key concept of weight loss outcomes with BS?
We measure excess weight-loss, not total weight loss
37
%EWL =
(Pre-op BW - CBW) / (Pre-op BW - IBW) x100
38
What is important to communicate about weight to a BS candidate
- That by BMI, they still may be considerd as "obese"
| - However, the are likely to have great metabolic improvements
39
Who may lose more than the average BS patient? Who is the average BS patient?
- Men, younger, and those of lower pre-op weight
| - Woman, >40 y/o
40
What is the significance of the metabolic improvements seen with BS?
- 5-10% weight loss is known to have metabolic improvements
| - BS results in 45-70% of excess weight lost
41
How will diabetes be resolved only 24-hours after BS surgery despite no weight loss yet?
Change in gut-hormones, such as an increased GLP-1
42
Why does surgery for bariatric patients have a good risk:benefit ratio?
Obese patients often have a higher rate succumbing to their weight within 5 years rather than the surgery itself
43
AGB %EWL?
46%
44
AGB resolution of DM2?
58%
45
SG %EWL?
50-60%
46
SG resolution of DM2?
60%
47
RYGB %EWL?
60%
48
RYGB resolution of DM2?
71%
49
BPD-DS %EWL?
64-70%
50
BPD-DS resolution of DM2?
96%
51
What is the reduction in mortality after 5 years pot RYGN?
89%
52
What are the weight-loss outcomes after 12 months post-op?
- rapid weight loss occurs over the first 12 months post-op
| - However, the most significant weight loss is seen in the first 6 months post-op
53
What is the significance of most weight loss occurring within 1 year post-op?
- The surgery doesn't grant an indefinite period of weight loss
- After this initial loss, the surgery has "done its work" and the rest is on the patient
54
What is the goal outcome in BS?
Weight reduction to improve overall health
55
What are the 3 key mechanisms which promote weight-loss post-op?
1) Gastric restriction
2) Common-limb length
- Gut hormones
56
Which surgeries cause gastric restriction?
All of them
57
Which surgeries result in a common limb, of varying lenghts?
- RYGB
| - BPD-DS
58
Which surgeries result in an alteration of gut hormones?
- RYGB
- Sleeve
- BPD-DS
59
Discuss how common limb length can result in weight-loss
-Only are where pancreatic/gastric juices will mix with foods - therefore the only length where absorption is possible
60
Which gut hormones change?
- Decrease in ghrelin
| - Increase in leptin
61
Why does ghrelin decrease?
Due to the removal of the gastric fundus, which contain the parietal cells which secrete ghrelin
62
What do we need to consider when a patient indicates that they are hungry
Where is this "hunger" coming from? Is it psychological or is it true hunger?
63
Common early complications (<30 days post-op?)
- Bleeding
- Anastomotic leak
- Infections
- Strictures
- Obstructions
64
What is an anastomotic leak?
The anastomosis (surgical stitches have not fused properly with the tissue, causing a leak which can be fatal
65
What is a stricture?
When tissue heals, it tightens. If it tightens too much is can create a stricture
66
Common late complications (>30 days post-op?)
- Nutritional deficiencies
- Dumping syndrome
- Weight-regain or weight los failure
- Malnutrition
- Ulcer
- Stricture
- Psychological complications
67
Discuss the pre-op nutritional guidelines
- Very low calorie diet 2 weeks prior to surgery (800-900 kcal)
- Low carb (<100g/day), high protein and moderate fat
- Will induce ketosis
68
What is the rationale behind the pre-op nutritional guidelines?
- Reduce the size of the liver by decrease intrahepatic fat
- Improve visibility for surgeons
- Reduce surgical risks
69
Nutritional guide-lines post-op?
- CF (1-3 days)
- FF/Puree (5 wks)
- Solids (for life)
- With portion progression
70
What is the rational behind the pos-op nutritional guidelines?
- Reduce vomiting and allow healing of anastomosis
| - Portion control to habituate patient to their new gastric pouch
71
What is the portion progression?
- 1/2 cup to start
| - Increase to 1 cup portions per meal/snack
72
Discuss why vitamin and mineral deficiencies are common post-op
- Reduced dietay intake
- Removal of fundus --> less parietal cells --> less HCl
- Bypassed intestines
- tolerance issues
73
Which nutrients are of particular concern when HCL is reduced?
- Calcium
- Iron
- No activation of IF, less B12
74
Key nutrient absorbed in the duodenum?
-Calcium
| 0Iron
75
Key nutrients absorbed in the jejunum and proximal ileum?
- Folate
- Vitamin D
- Fat soluble vitamins
- Copper
- Zinc
76
Ke nutrients absorbed in the terminal ileum?
- Vitamin B12
| - Bile salts
77
What is the issue with nutrient deficiencies and lab work?
-We are often not testing for copper or zinc, therefore we may have to rely on physical signs
78
Which surgery has a greater risk of deficiencies of fat soluble vitamins?
- BPD/DS
| - Common channel doesnt form until after the proximal ileum
79
Why would we prefer using calcium citrate instead of calcium carbonate after the bariatric surgery?
- There is less HCl produced
- Calcium citrate will be more absorbed as the citrate is acidic, thus allowing for the breakdown and absorption of calcium
80
Why is vitamin B1 (thiamine) important to supplement?
-Has a short half-life, rapidly depleted
81
What are the two kinds of protein deficiencies observed after BS?
-Primary and secondary protein-malnutrition (PM) or protein-energy malnutrition (PEM)
82
Discuss primary PM and PEM
- Rare, but at risk in all BS
- Due to decreased oral intake an volume restriction
- Significant loss of LBM
83
Discuss secondary PM and PEM
- Rare in RYGB, uncommon in BPD/DS
| - Due to malabsorption
84
What may aggravate PM/PEM in a BS patient?
-BS patients often have a "diet-mindset" and will only fill their plates with veggies, however we need to switch them to a "protein" mindset
85
When does most LBM occur? Why?
- Within 3-months post-op
- Patients are adjusting to new intakes, may be experiencing nausea, vomiting, discomfort and issues tolerating foods and incorporating protein
86
What is the significance of reduced LBM?
-Will lead to reduced RMR, muscle strength and physical function
87
What is the goal within the context of LBM?
-Inevitable loss, put try to preserve as much LBM as possible
88
Why do protein needs increase for some surgeries?
Not because their true requirement is higher, but their absorption is lower
89
Protein for band, sleeve or RYGB?
1. 0-1.5 g/kg/day
| - 60-120 g/day
90
Protein for BPD/DS?
1.5-2.0 g/kg/day
91
Key recommendation with protein?
- Focus on high biological value and high quality proteins
| - High PDCAAs
92
Example of high PDCAAS?
- Egg white
- Casein
- Whey
- Soy
93
Low PDCAAS?
- Collage
| - Gelatin
94
Why may some people choose low PDCAAS?
- Tastes better
| - Less volume for same amount of protein
95
Most common equation to estimate energy needs?
Mifflin-St-Jeor
96
What is the issue with MFSJ?
-Often severely overestimates after surgery, and severely underestimates after surgery
97
What is the main issue with tolerance post-op?"
People are not tolerating normal foods
- HCl decreases
- No more stomach churning/grinding
- No pyloric sphincter (dumping, diarrhea)
- Constipation
- Dysgeusia
- Food intolerances
- Smaller portion sizes, delaying fluids
98
What is an important recommendation regarding chewing foods?
- Post-op, stomach does not have same churning activity
| - Chew thoroughly until food is consistency of applesauce prior to swallowing
99
Discuss delaying fluids and dehydration post op
- Easy to become dehydrated after sx as we must delay fluids
| - Only small sips throughout the day and cannot drink with meals
100
How much water can the stomach tolerate?
Less than 1 cup
101
What may induce diarrhea
- Lactose
- Dumping syndrome
- Sugar alcohols (often found in diet products, low-sugar products)
102
Dietary modifications?
- Limit liquid calories, but hydrate (delay fluids)
- 1/2 pro, 1/4 veg, 1/4 grains
- Reduce eating out
- Decrease processed foods/simple sugars
- Decrease high fat foods
103
Behaviour modification?
- No skipped meals
- Prolong meals (cut in 1/2, but must eat later)
- Chew well
- Portion control
- Pay attention to satiety signals, mindful eating
- Avoid drinking with meals/snakcs
104
Guidelines for delaying fluids?
No fluids:
- 15 minutes before meals
- 30 minutes after meals
105
Case: Patient 6wk S/P gastric bypass presents with vomiting. What do you rule out?
- Esophageal dysphagia
| - Structure
106
how could we investigate esophageal dysphagia?
- Are they chewing well?
- Are you overeating?
- Are you eating too quickly??
- What kind of textures are you eating?
- What kind of preparation methods are you using?
107
If esophageal stricture is rules out, how should we proceed?
- Suspect possible stricture
| - Need to see doctor or nurse to rule out a stenosis - investigate via gastroscopy and ballon dilation
108
Nutritional intervention within the case of a stricture?
- Suggest liquid meal replacement
| - Supplements, shakes, protein water
109
Case: Patient S/P 1 year gastric bypass, presents with shakiness, sweats, nausea and feeling unwell 3-4 days/week. What is your impression?
- Rule out hypoglycemia and it's sources
| - Investigate possible dumping syndrome
110
How could we rule of hypoglycemia?
-Check blood glucose levels, consider if diabetic
111
How can we investigate dumping syndrome?
- Onset of symptoms as related to last meal/snack
- Type of food consumed
- Presence of diarrhea
112
Questions to investigate dumping syndrome?
- What kind of meal are you eating?
- Does it happen at a certain moment?
- What types of foods? Simple sugars?
113
When is dumping syndrome most common?
In those surgeries where the pyloric sphincter is removed, with RYGM
114
What is the early phase of dumping syndrome?
- Occurs 10-30 mins PC
- Due to the rapid transit of hyperosmotic food into the jejunum (usually simple sugars)
- Symptoms include dizziness, nausea, weakness, rapid pulse and diarrhea
115
What is the late phase of dumping syndrome?
- Occurs 1-3 hours PC
| - Reactive hypoglycemia due to an exaggerated release of insulin
116
(T/F) Dumping syndrome is typically only caused by eating simple sugars (candies, desserts, ice cream etc)
F
| Could be seen with an excess of fruit with an absence of fibre, fat or protein (smoothies, juice etc)
117
Is dumping syndrome seen with CHOs, such as bread, potatoes and whole fruit?
Not usually
118
Why does reactive hypoG occur in the late phase?
When undigested food touches our bowel, our body will send out an untitrated surge of insulin which will elicit the hypoG response
119
What would be our nutritional intervention within the context of dumping syndrome?
- Healthy snacking, label reading
- Avoidance of trigger foods, limiting simple sugars
- Label reading, net carbs (= 25 g of absorbable carbs)
120
Case: Patient S/P gastric bypass 1 yea, reports shakiness, sweats, nausea and feeling unwell 3-4 times per week. His diet is not indicative of dumping syndrome (high carb, low protein lunch, but no simple sugars? What is your impresion?
- Diet not likely inicative of dumping syndrome
| - Rule out possible nesidioblastosis
121
What is nesidioblastosis?
Hyperinsulinemic hypoglycemia
-Many BS patients have insulin resistance, and the concentration os insulin will remain the same even though their resistance has improve with the weight los
122
Nutritional intervention with nesidioblastosis?
Increase protein:carb ratio at lunch with PM snack
| If no improvements, refer to endocrinologist
123
Case: Patient S/P surgery 4 mo and complains of hair loss. What is your impression?
- Likely "shock loss" due to catabolic stress of Sx (telogen effluvium)
- Occurs between 3-6 mo post op
- Check adequate protein and vitamin/mineral compliance
124
Case: Patient S/P BPD-DS 2 yr has been losing lots of hair over the last two months. What is your impression?
- Hair loss at this stage in rare
- Investigate via dietary assessment and bloodwork
- Ensure proper protein intake, and also verify vitamin and mineral supplements (i.e. not al MVs will be adequate)
125
What is the prevalence of inc deificiency in post-op BPD-DS patients?
70%
126
What are the symptoms of zinc deficiency?
- Hair loss
| - Dysgeusia
127
What is the zinc supplementation recommendation post BPD-DS?
16-22 mg of zinc sulfate/day
128
When may we suspect zinc deficiency?
- hair loss begins >6-9 months post-op
- Attaining protein needs
- Insufficient zinc supplement
129
Nutrition intervention for zinc deficiency?
- Supplement 60 mg of zinc BID
- Monitor plasma zinc in bloodwork
- Suggest complete multivitamin to patient
130
Case: A patient returns to see you 14 months after surgery, she has regained 25lbs, C/O of always being hungry, can tolerate more food and is discouraged. What is your impression
- Likely not delaying fluids
| - Review dietary and drinking habits
131
What are causes for weight regain which is not habit based?
- Poorly controlled thyroid
- New medications (antidepressants)
- Stopped exercising
- Surgical reasons, such as fistulas
132
Case: Patient has gained 60lbs, and is not making changes despite counselling and nutritional intervention. What is your next course of action?
- Suggest benefits of seeing a psychologist for better management of her emtions, and dietary counselling has not provided a solution to her emotional eating thus far.
133
Case 5: A patient is admitted to the hospital with an anastomotic leak (can be fatal, as the gastric contents leak into the abdomen). What is your intervention?
- TPN
| - No EN, as the bowel needs to be at rest to encourage the healing process
