Bariatric surgery Flashcards
Health Implications of Obesity
Hypertension or high blood pressure coronary heart disease, dyslipidaemia type two diabetes stroke gallbladder disease liver disease such as non-alcoholic fatty liver disease osteoarthritis obstructive sleep apnoea and other breathing problems some cancers such as breast, colon and endometrial cancer mental health problems
What is the trend in obesity across ages?
Increases with age between 20-65 years old, followed by a decline
Not due to weight loss but due to high mortality obese people
What is the trend in death from obesity across years?
Risk of death increased from 1985 to 2000
Obesity classes according to BMI
Obese class 1: 30.0 – 34.9 Obese class II: 35.0 – 39.9 Obese class III: (Morbid Obesity): ≥ 40.0
What is the purpose of bariatric surgery
promote significant weight loss and assist/improve weight-related comorbidities
Bariatric surgery associated terms
Weight loss surgery
Obesity surgery
Metabolic surgery
Indications for bariatric surgery
BMI ≥ 40, or
BMI > 35 with significant obesity-related comorbidities
Acceptable operative risk
Failure of non-surgical weight loss
Well-informed, compliant, and motivated patient
Contraindications to bariatric surgery
Active substance abuse (drugs, alcohol) Uncontrolled psychiatric illness Cirrhosis Pulmonary hypertension Severe cardiac and respiratory disease Active pregnancy
eating disorder is not a counter-indication for surgery
Types of surgeries
- Restrictive procedures (restriction of stomach volume)
- Adjustable gastric band (AGB)
- Vertical sleeve gastrectomy (VSG)- most common type - Restrictive + Malabsorptive procedures (restriction of stomach volume + manipulating the intestines)
- Roux-en-Y gastric bypass (RYGB)
- Biliopancreatic diversion with duodenal switch (BPD/DS)
Characteristics of AGB
Adjustable gastric band (AGB)
- Reversible
- Rapid,satiety
- Requires frequent adjustments
- Unknown durability of the band
sodium can be injected into the port to inflate the band and cause more restriction
leaking-> more sodium has to be injected
too tight-> will result in vomiting
Characteristics of sleeve gastrectomy
Most of the fundus is remove (70-80% )
Pyloric sphincter and intestines remain intact
Rapid satiety
irreversible
done through laparoscopy-> less infection and pain, better and faster recovery
describe Roux-en-Y Gastric Bypass (RYGB)
pyloric sphincter is no longer used-> this can lead to rapid gastric emptying
- New gastric pouch is created, excludes the fundus
- bypass of the duodenum and proximal jejunum
- Malabsorption: pancreatic and gastric enzymes reach the proximal jejunum at the anastomoses
- rapid satiety
https: //www.youtube.com/watch?v=vvN4z0lb3A8&ab_channel=NorthwellHealth
Describe Biliopancreatic diversion with duodenal switch (BPD-DS)
Not for everyone, but in case it is done- very effective
pyloric sphincter is used
biggest weight loss
- Sleeve gastrectomy and stomach resection ,
- Common limb ~100m of the ileum
- more malabsorption than RYGB-> pancreatic and gastric and enzymes reach the ileum at the anastomosis
- one or two stage procedure
how to calcualte excess weigth loss?
100× (preoperative weight−initial weight)/ (preoperative weight - ideal weight)
name bariatric surgeries from biggest excess weight loss to smallest
Switch
RYGB and Sleeve gastrectomy
AGB
name bariatric surgeries from biggest % of DM2 resolution to smallest
Switch
RYGB
Sleeve gastrectomy
AGB
rate of weigth loss post-op
- Rapid weight loss occurs over first 12 months post-op
- Most significant loss seen in the first 6 months post-op.
realistic goals post-op
- As per %E WL, individuals may still be categorized as ‘obese’.
- Few patients arrive to their ideal body weight (IBW) as per BMI.
- Goal is for weight reduction to improve overall health outcomes.
Mechanisms of weight loss of surgeries
- Gastric restriction (all surgeries)
- Common limb length (RYGB, BPD-DS): Shorter common limb = more malabsorption
- Gut hormones get altered by surgery (RYGB, sleeve, BPD-DS) - effect subdues after some time, but still will be less than before surgery
↓ Ghrelin (orexigenic hormone) secretion: Produced by the parietal cells (in gastric fundus), which is removed. !
↑ Leptin (produced by adipocytes)
what is a common limb?
common limb is where gastric content and pancreatic juices join
True or False?
! Bariatric surgery resolves type 1 and type 2 diabetes?
FALSE
Can only (possibly) resolve DM2 if <10 years since diagnosis- if 10+ years there is already pancreatic fatigue and organ damage
But weight loss surgery will still improve insulin response
early and late complications of surgery
Early (< 30 days post-op):
- Bleeding, anastomotic leak (risk of tissue not fusing together-> stomach contents leak into abdomen), infection, strictures (strictures most commonly occur with bypass), obstructions
Late (> 30 days post-op):
- Ulcer, stricture, obstruction, hernia, nutrition deficiencies, dumping syndrome, weight regain or weight loss failure, psychological complications, malnutrition
Nutrition Guidelines: PRE-OP
Very low calorie diet (VLCD) 2 weeks prior to surgery
- 800-900 calories
- Low carb (<100g/d), high protein, moderate fat
- Induces ketosis- the point is to get smaller liver size to have a better visibility and lower surgical risk
smaller size is achieved through ketosis
Reduces liver volume by decreasing intrahepatic fat
- Improves visibility for surgeons
- Reduced surgical risks
Nutrition Guidelines: POST-OP
Texture progression:
- To reduce vomiting and allow healing of anastomosis
1. Clear fluids (1-3 days)
2. Full fluids/puree (5 weeks)
3. Solids (for life)
Portion progression:
- 1⁄2 cup to start, ↑ to 1 cup portions per meal/snack
- To reduce vomiting and habituate patient to their new gastric pouch.