Bariatric Surgery Flashcards
1
Q
Postprandial RUQ pain and nausea months after RYGB should raise concern for
A
Gallstones
2
Q
Recommended iron intake through supplements postop
A
40-65 daily
3
Q
Bariatric procedure that is sometimes done as an outpatient
A
Band
4
Q
Symptoms of internal hernia
A
Vary, but generally pain N/V and signs of obstruction
5
Q
Treatment of postop stricture/stenosis
A
EGD with dilation
6
Q
Pleural effusion soon after surgery is concerning for this complication
A
Leak
7
Q
Urinary calcium postop screening
A
24 hour urinary calcium recommended at 6 months and then annually after that
8
Q
Thiamine supplementation post op
A
Recommended as mineral component of multivitamin
9
Q
Change in Grehlin with Bariatric surgery
A
Decreased
10
Q
Indications for Biliopancreatic Diversion (with duodenal switch)
A
Sometimes used for severely obese (BMI >50)
Sometimes used for revision of other procedure if failed to lose weight or had weight regain
11
Q
Test for bacterial overgrowth syndrome
A
Lactulose breath test
12
Q
Timing of weight regain
A
Usually about 2 years postop
13
Q
Perioperative management of hormone replacement therapy and OCPs
A
Estrogen therapy should be discontinued before bariatric surgery (1 cycle of oral contraceptives in premenopausal women; 3 weeks of hormone replacement therapy in postmenopausal women) to reduce the risks for post-operative thromboembolic phenomena
14
Q
Contraindications for Bariatric surgery
A
Hasn’t tried multiple rounds of lifestyle modification +- meds
Poor adherence (severe psych, dementia, substance abuse …)
Eating disorder
Crohns
Smoker (not able to quit)
(Many) prior abdominal surgeries can complicate things
Pediatric patient not yet done with puberty and linear growth
Patients >60 years old less commonly done, but possible if good functional age
General medical contraindications to surgery
15
Q
Esophageal dilation is seen after this type of procedure
A
Band
16
Q
Treatment of Dumping syndrome
A
Decrease simple cabs, increasing protein/fat/fiber, not drinking fluids with meals, avoiding dairy, and eating smaller more frequent meals
17
Q
Thiamine deficiency seen most often after this type of procedure
A
RYGB or BPD
18
Q
Extended release and enteric coated medicaitons post op
A
Absorption may be altered so use should be avoided
19
Q
Treatment for bile salt toxicity
A
Cholestyramine
20
Q
Timing of return to work after bariatric surgery
A
Usually directed to stay out of work for 1-2 weeks after band and 2-4 weeks after sleeve/RYGB
21
Q
Change in gastric emptying after Bariatric surgery
A
Increases
22
Q
Timing of onset of symptoms of internal hernia
A
Varies greatly. Can be soon after surgery or years later. Most often about a year after procedure
23
Q
The most common cause of SBO after bariatric surgery is
A
Internal hernia
24
Q
What percentage of lap bands end up needing revision?
A
1/3
25
Thiamine postop screening
Only if specific findings
26
Expected weight loss with RYGB
~35% total body weight (~65% excess body weight)
27
Preop Testing recommended by 2013 Guideline from AACE/TOS/ABMBS
```
CBC
Lipids
CMP
UA
PT/INR
Blood type
Iron
B12
Folic Acid
Vit D
H pylori screening of high prevalence area
CXR
EKG
OSA screening (with sleep study if positive)
```
Eval for other obesity related comorbidities based on clinical suspicion
TSH only if clinical suspicion
28
Vit B12 supplementation postop
As needed to check levels within normal range
29
Change in energy expenditure after Bariatric surgery
Decreases (less tissue to support)
30
Timing of postop thiamine deficiency
Thiamine Deficiency and Wernicke Korsakoff most often in the 3 months immediately following surgery
31
Best contraceptive after bariatric surgery
Procedures with a malabsorptive feature (Sleeve and RYGB) may decrease absorption of OCP, so other options preferred
32
Perioperative sulfonylurea use
Should be stopped after surgery to avoid hypoglycemia
33
What most consistently predicts maintenance of weight loss of Bariatric surgery
Exercise
34
Cause of tachycardia, dizziness, diaphoresis, and palpitations 10-30 min after eating
"Early" Dumping syndrome
Quick movement of food through stomach into the bowel --> hyperosmolality of the food and rapid fluid shift into the bowel --> hypotension and sympathetic nervous response
35
Effects on long term Bariatric outcomes and complications for patient who lose weight preop? Should it be required to qualify for surgery?
There is a lack of consensus about the role of preop weight loss in improving outcomes with mixed evidence.
Preop weight loss may slightly decrease complications by decreasing adipose tissue and liver size.
Some studies show patients who are able to lose weight prior to surgery have more weight loss after surgery.
Per ASMBS, the requirement of insurance companies to lose weight to qualify for surgery is discriminatory, arbitrary, and not scientifically founded with delays in procedures. Some of the insurers who require preop weight loss don’t reimburse for these services, so are clearly more doing it to limit access not improve outcomes
36
Change in recommendations for carb intake in patients with dumping syndrome
Less simple carbs
More complex carbs
37
Rank procedures in frequency of nutritional deficiencies post op
Band (least)
Sleeve
RYGB
Biliopancreatic diversion (most)
38
Use of NSAIDs and smoking increase the risk of this particular postop complication
Marginal ulcer
39
Bariatric procedures with the most post op (30 day mortality)
Biliopancrratic diversion with duodenal switch and RYGB
40
Leak can present with pain in the abdomen and/or _
Shoulder
41
Meds for short gut (if needed)
Antidiarrheals
PPI/H2 blocker
42
What is short gut syndrome and how is it treated
Diarrhea and possibly malnutrition caused by a lack of absorptive surface seen after RYGB in the weeks after surgery. Body can adapt overtime and improve. Hydration, dietary modification, acid suppressing medications (H2 or PPI) and antidiarrheals are used
43
Effect of bariatric surgery on appetite
Decreased
44
This procedure has the highest rate of (long term) post op complications
Band, why falling out of favor
45
Mechanism of Bariatric surgery
Mechanical Restriction
Malabsorption
Change in microbiota
Change in GI hormones
Increased brown thermogenesis
...
46
Dumping syndrome most common after what type of procedure
RYGB (And BPD-DS)
47
Calcium supplementation postop
Calcium citrate 1200-1500 mg
48
Change is GLP-1 with Bariatric surgery
Increased
49
Effects of Bariatric surgery on a women’s offspring
Children born to women s/p Bariatric surgery are less likely to be obese
50
Preferred initial test for suspected leak
Upper GI series (X-ray) with oral contrast or CT with oral contrast
51
Bariatric surgery is generally not performed before what age in pediatric patients
Usually no earlier than 13 in girls and 15 in boys when they have reached >95% skeletal maturity
However, newer guidelines call this standard practice into question
52
Internal hernia are seen after this type of Bariatric surgery
RYGB
53
How to manage mild N/V and food intolerance in the weeks following surgery
Not uncommon after bariatric surgery. Due to a variety of causes. If mild and able to tolerate thin liquid diet probably don't need to return to the hospital. If symptoms mild kept on liquid diet for 1-2 weeks, and then slowly transitioned to solids. Likely caused by surgical edema which should resolve
54
Most common cause of perioperative mortality
DVT/PE or leak
55
Effects of Bariatric surgery on OSA
Improved apnea hypopnea scores but usually does not completely resolve it
Consider redoing sleep study before stopping CPAP
56
Effect of Bariatric surgery on cancer
Decreased breast, endometrial, prostate, pancreatic, and colon cancer
57
Prophylaxis for nephrolithiasis postop
Low oxalate diet
| Stay hydrated
58
Change in insulin secretion after Bariatric surgery
Increased
59
Medications used for Dumping syndrome
Fiber supplement can help
Acarbose or Octreotide sometimes used to treat dumping syndrome
60
Vitamin C supplementation post op
Can increase absorption of iron
61
Postprandial hyperinsulinemic hypoglycemia is also called
"Late" dumping syndrome
62
Treatment of suspected leak
Ex-lap
63
Marginal ulcer seen most often after this type of Bariatric procedure
RYGB or BPD
64
Recommendations for Pregnancy after Bariatric surgery?
Wait at least 12 months. High risk for nutritional deficiencies in mom and baby
65
Rank procedures in order of weight loss and effect on medical comorbidities
Biliopancreatic diversion (biggest)
RYGB
Sleeve
Band (least)
66
Effects of Bariatric surgery on depression
Improved, although suicide increases
SSRI bioavailability is lessened by bariatric surgery
67
Treatment for bacterial overgrowth postop
Rifaximin
Cipro
Metronidazole
68
Bariatric Surgery Criteria for Peds patients per AAP guideline
140% of the 95% for age/gender, BMI of 40 or class 3 obesity
If have clinically significant disease (OSA, DM, HTN, GERD, SCFE, NASH...), then only need to have 120% of the 95%, BMI of 35 or class 2 obesity
Should be done with most of linear growth
BMI criteria r the same as adults
69
Timing of kidney stones post op
Usually years postop
70
Effects of Bariatric surgery on HLD
Remission in roughly 40-80% of patients depending on procedure
Improvement in most
71
Effect of Bariatric surgery on alcohol absorption and elimination
In bypass surgery it is absorbed faster and eliminated slower with a slight increased risk for alcohol dependence
Sleeve and band have not shown these risks
72
Post op diet
Kept NPO initially, then thin liquid diet for 1-2 weeks before slowly advancing
Protocol driven staged meal progression should be supervised by registered nutrition per guidelines
73
Effect of Bariatric surgery on mortality
Long term significant decreased (although slight increase in the weeks immediately following surgery)
74
Change in CCK after Bariatric surgery
Increased
75
This vitamin deficiency should be suspected in patients with fatigue and loss of vibration/positional sense
Vit B12 cobalamin
76
Should the gallbladder prophylactically be removed during Bariatric surgery
No, per ABMS choosing wisely guideline
77
Tachycardia and pain in the immediate post op period should raise concern for these 2 complications
PE and leak
78
B12 Screening postop
Annually
79
Dietary changes after Bariatric surgery
Patients should be counseled to eat 3 small meals during the day
chew small bites of food thoroughly before swallowing.
Need to eat slowly
Avoid fluids during meals (wait 30 min) as decreases sense of fullness.
Avoid concentrated sweets which can cause dumping syndrome.
Avoid carbonated beverages as can cause gastric bloating.
Lactose intolerance is often worsened by bariatric surgery. Usually directed to limit dairy especially in the weeks following surgery
80
How to handle smoker who wants Bariatric surgery
Significantly increases multiple complications. Need to stop before surgery, preferably at least6 weeks before hand
81
What is the most common vitamin def after RYGB
Iron
Due to less red meat and exclusion of duodenum
82
Effects of Bariatric surgery on osteoarthritis
Improved
83
Post Op diarrhea causes and treatments
Lactose intolerance is often worsened by bariatric surgery. Usually directed to limit dairy especially in the weeks following surgery
Decrease bile acid absorption. Cholestyramine sometimes used to bind bile and decrease diarrhea
Change in gut micobiotica and C Dif. Probiotics often given postop
Short Gut syndrome
Dumping syndrome
Pancreatic insufficiency
Imodium sometimes used daily postop
84
Most common site of anastomitc leak
Gastro-jejunal anastomosis in RYGB
Can also occur at staple line in sleeve
85
Vitamin D supplementation post op
At least 3000 units, and then additionally titrate to keep level above 30
86
Work up of complicated dumping syndrome can include
Glucose challenge test and sometimes gastric emptying study or insulin/C-peptide studies
87
Treatment of marginal ulcer
Carafate and PPI with treatment of H pylori if present
88
How long to make vitamin supplements chewable postop
3-6 months
89
Qualifications for getting Bariatric surgery
Per 2014 ACC/AHA/Obesity Society guidelines
- BMI >=40
- BMI >=35 + comorbidites
Per American Association of Clinical Endocrinologists guideline also candidate if BMI 30-35 with type 2 DM or metabolic syndrome. But evidence for this is limited
90
Expected weight loss with sleeve
~25% of total body weight (~55% of excess body weight) over 1-2 years
91
Use of this type of medication is thought to increase the risk of anastomotic leak in Bariatric patients and should be avoided post op
NSAIDs
92
What should be taken along with Orlistat
Multivitamin due to risk of fat soluble vitamin deficiency
Fiber (Psylium) supplement decreases side effects
93
Vitamin K screening postop
Not recommended
94
What is done during a Roux-en-Y Gastric Bypass procedure
End up disconnecting most of the stomach and duodenum from the esophagus. Create small remaining stomach pouch that connects directly to the small intestine bypassing duodenum and stomach. You don’t completely remove the stomach and duodenum so can continue to get secretions even though they no longer receive food
95
What is bacterial overgrowth syndrome & what causes it
Bacterial overgrowth syndrome is a disorder in which poor movement of intestinal contents allows certain normal intestinal bacteria to grow excessively, causing diarrhea and poor absorption of nutrients (malabsorption).
96
Change in Leptin after Bariatric surgery
Decreased
97
Expected time in the hospital for sleeve and RYGB
1-2 days
98
This complication seen immediately after surgery is higher risk in severely obese patients and those with longer procedures
Rhabdo
Check CK post op especially in patients with BMI >55
99
Trends in Popularity of Bariatric surgery overall
Only about 1% of people in the US who meet criteria end up having it done, despite 60% having insurance coverage for it
Number of Bariatric surgeries worldwide has plateaued
100
Folic acid supplementation post op
Folic acid supplementation (400 mg/d) should be part of a routine mineral-containing multivitamin preparation
101
This Bariatric procedure requires the most frequent follow up post op
Lap Band, requires frequent adjustments
102
This vitamin deficiency should be suspected in patients with heart failure, nystagmus, sensory/motor deficits, and AMS
Thiamine B1
103
Postop Screening of Vit A
Generally not recommended
Optional for RYGB
104
What to suspect in the first couple weeks of Bariatric surgery if patient has severe abdominal pain (or shoulder), SOB, fever, and tachycardia
Leak
105
Most popular bariatric procedure
Sleeve
106
Vitamin E screening postop
Not recommended
107
Bariatric surgery with the least post op (30 day) mortality
Band
108
Effects of Bariatric surgery on HTN
Remission is relatively common (50-75% depending on procedure)
109
How to decrease rates of Rhabdo
Padded surgical tab
Limit operative time
Hydrate perioperatively
110
Preferred testing if suspect marginal ulcer
EGD with H pylori biopsy
111
Severe N/V and food intoelrance soon after band procedure is likely
Stomal obstruction/band stricture
112
Multivitamin use postop
2 adult multivitamin plus minerals (containing iron, folic acid, copper, and thiamine) after RYGB and Sleeve. Band only needs 1 daily
113
Effects of Bariatric surgery on GERD
RYGB decreases GERD
Sleeve worsens GERD
114
A patient s/p bypass has microcytic or normocytic anemia, sensory ataxia, spastic gait, weakness fatigue, normal iron, normal folate, normal B12, and ringed sideroblasts on smear. This is caused by what?
Copper deficiency
115
Dumping syndrome seen most often after this type of Bariatric surgery
RYGB or BPD
116
Expected weight loss with band
~15% total body weight (~40% excess body weight) at 2 years
117
What is done during a laparoscopic adjustable band procedure?
Band placed at the top of the fundus of the stomach below the esophagus and connected to port in the upper abdomen which allows you to adjust the tightness of the band based on satiety
118
Effects of Bariatric surgery on suicide
Roughly 50% increase
119
"Swirl sign" on post op imaging is suggestive of _
Internal hernia
120
What does a sleeve gastrectomy involve doing?
Partial vertical gastrectomy along the greater curvature of the stomach removing about 70% of its volume
121
Risk of mortality in perioperative period
Much lower than other common procedures
30 day mortality:
* CABG 2.8%
* Lap chole 1.8%
* Lap appy 1.5%
* RYGB 0.3%
* Lap Sleeve 0.2%
* Lap Band <0.05%
122
Effects of Bariatric surgery on quality of life
Improved
123
Band brands
Lap Band
| “Realized Band” (no longer available)
124
Prophylaxis for post op gallstone formation
Not routinely recommended but some docs treat with Ursodeoxycholic acid for about 6 months postop
125
Dumping syndrome is most often seen after what type of Bariatric surgery
RYGB (and biliopancretic diversion)
126
This vitamin deficiency should be suspected in patients with peripheral edema
Thiamine B1
127
Blood in stool should raise concern for this post op complication in the early postop period
Marginal ulcer
128
Flank pain a few years after RYGB should raise concern for
Nephrolithiasis
129
Copper supplementation post op
Copper supplementation (2 mg/d) should be included as part of routine multivitamin with mineral preparation
130
Effects of Bariatric surgery on diabetes
Remission is relatively common (~40-80% depending on procedure)
High percentage of at least improvement and/or get off insulin
Recurrence of diabetes later is not uncommon but usually much less severe then before
131
Management of internal hernia post-bariatric surgery
Urgent surgical referral. Can lead to bowel ischemia
132
Pain meds after surgery
Usually liquid elixir Oxycodone, but can also take tylenol
No NSAIDs
133
Should prophylactic antibiotics be used postop
No, per ABMS choosing wisely guideline
134
N/V, abdominal pain and dysphagia a few weeks post op should raise concern for
Stricture/stenosis
135
This is the only Bariatric procedure that is reversible
Band
136
Effects of Bariatric surgery on PCOS
Appears to improve PCOS
137
Should you do routine screening for gallstones preop
No
138
Iron screening post op
Highly recommended
139
Cause of tachycardia, dizziness, diaphoresis, and palpitations 1-3 hours after eating
"Late" Dumping syndrome
Rapid absorption of sugars --> surge of insulin --> hypoglycemia
140
Timing of gallstone related issues postop
Usually within 3-6 months of surgery
141
Preferred form of Calcium supplement
Citrate
142
Change in Peptide YY after Bariatric surgery
Increased
143
Importance of intraoperative or routine post op leak testing
Routine use of intraoperative or immediate postop leak testing with air/dye/endoscopy is not an evidence based practice, but is commonly done.
144
Bone density screening postop
At 2 years
