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Clinical 3 > Bariatric surgery > Flashcards

Bariatric surgery Flashcards

1
Q

Health Implications of Obesity

A 
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
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2
Q

What is the trend in obesity across ages?

A

Increases with age between 20-65 years old, followed by a decline
Not due to weight loss but due to high mortality obese people

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3
Q

What is the trend in death from obesity across years?

A

Risk of death increased from 1985 to 2000

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4
Q

Obesity classes according to BMI

A 
Obese class 1: 30.0 – 34.9
Obese class II: 35.0 – 39.9
Obese class III: (Morbid Obesity): ≥ 40.0
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5
Q

What is the purpose of bariatric surgery

A

promote significant weight loss and assist/improve weight-related comorbidities

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6
Q

Bariatric surgery associated terms

A

Weight loss surgery
Obesity surgery
Metabolic surgery

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7
Q

Indications for bariatric surgery

A

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

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8
Q

Contraindications to bariatric surgery

A 
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

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9
Q

Types of surgeries

A
  1. Restrictive procedures (restriction of stomach volume)
    - Adjustable gastric band (AGB)
    - Vertical sleeve gastrectomy (VSG)- most common type
  2. Restrictive + Malabsorptive procedures (restriction of stomach volume + manipulating the intestines)
    - Roux-en-Y gastric bypass (RYGB)
    - Biliopancreatic diversion with duodenal switch (BPD/DS)
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10
Q

Characteristics of AGB

A

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

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11
Q

Characteristics of sleeve gastrectomy

A

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

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12
Q

describe Roux-en-Y Gastric Bypass (RYGB)

A

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
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13
Q

Describe Biliopancreatic diversion with duodenal switch (BPD-DS)

A

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

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14
Q

how to calcualte excess weigth loss?

A

100× (preoperative weight−initial weight)/ (preoperative weight - ideal weight)

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15
Q

name bariatric surgeries from biggest excess weight loss to smallest

A

Switch
RYGB and Sleeve gastrectomy
AGB

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16
Q

name bariatric surgeries from biggest % of DM2 resolution to smallest

A

Switch
RYGB
Sleeve gastrectomy
AGB

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17
Q

rate of weigth loss post-op

A
  • Rapid weight loss occurs over first 12 months post-op

- Most significant loss seen in the first 6 months post-op.

18
Q

realistic goals post-op

A
  • 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.
19
Q

Mechanisms of weight loss of surgeries

A
  • 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)
20
Q

what is a common limb?

A

common limb is where gastric content and pancreatic juices join

21
Q

True or False?

! Bariatric surgery resolves type 1 and type 2 diabetes?

A

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

22
Q

early and late complications of surgery

A

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

23
Q

Nutrition Guidelines: PRE-OP

A

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
24
Q

Nutrition Guidelines: POST-OP

A

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.
25
Q

Causes of Vitamin & Mineral deficiencies in bariatric surgery

A
  • Reduced dietary intake
  • Removal of fundus (less parietal cells): Reduced gastric acidity (hydrochloric acid - HCl-> less protein denaturing, lower iron absorption ) and Reduced intrinsic factor (IF)-> lower b12 absorption)
  • Bypassed intestines
  • Tolerance issues-> thus avoiding certain foods and missing nutrients from them
26
Q

RYGB associated deficiencies

A

Duodenum: calcium and iron
Jejunum: Vit D, folate
Ileum is untouched in procedure but due to less fundus- > less intrinsic factor-> less B12

27
Q

BPD/DS associated deficiencies

A

Deficiencies of fat soluble vitamins (ADEK) at greater risk with BPD/DS.
Duodenum: calcium and iron
Jejunum: Vit D E A K, folate
Ileum is untouched in procedure but due to less fundus- > less intrinsic factor-> less B12

28
Q

Are there protein concerns with bariatric surgery?

A

Primary protein malnutrition (PM) or protein-energy malnutrition (PEM)

  • Rare but at risk in all bariatric surgeries
  • Due to decreased oral intake/volume restriction

Secondary PM or PEM

  • RYGB (rare) and BPD-DS (uncommon, but possible)
  • Due to malabsorption have higher protein needs
29
Q

LBM loss

A
  • Most LBM loss occurs within 3 months post-op.
  • LBM loss may lead to reduced RMR and reduced muscle strength and physical function.

Importance:
- Inevitable lean body mass (LBM) loss, but try to minimize as much as possible.

30
Q

protein recommendations

A

Band, sleeve, RYGB: 1.0-1.5 g/kg IBW (~60-120g/d)
BPD/DS: 1.5 – 2.0 g/kg IBW (~90-120 g/d)

Focus on high biological value/high quality protein.

  • High PDCAAS: egg white, whey, casein, soy
  • Low PDCAAS: collagen, gelatin
31
Q

Dietary modifications

A
  • Limit liquid calories…but hydrate! Low kcal, low caffeine, low sugar, no carbonation
    Order of meal consumption: 1. protein 2. vegetables 3. grains
  • Reduce frequency of eating out
  • Decrease processed foods/simple sugars
  • Decrease high fat foods
32
Q

Behavior modification

A 
! No skipped meals
! Prolong meals
! Chew well
! Portion control (use smaller plates)
! Attention to satiety signals
! Practice mindful eating
! Avoid drinking with meals/snacks: 15 min AC; 30 min PC Because if liquid will mix with solid it will pass the stomach much faster-> rapid gastric emptying-> will get hungry faster
33
Q

A 27 y.o. female reports:
“I had a gastric bypass 6 weeks ago. I vomit almost everything that I eat.”
“I vomit everything I eat, even puree textures, but I can drink water.”

A

ule out: esophageal dysphagia (difficulty swallowing) vs stricture (narrowing at anastomosis) vs ?

Investigate causes:
! Poor chewing
! Overeating
! Eating too quickly
! Eating tough/fibrous foods, doughy breads, dry meat
! Stricture

Since she can drink-> possible stricture-> Needs to see doctor or nurse to rule out a stenosis. May need further investigation via a gastroscopy and possible balloon dilatation.

Nutrition Intervention:
! Can suggest meal replacements to optimize nutrition as much as possible.

34
Q

A 42 y.o. man reports symptoms of shakiness, sweats, nausea, and feeling very unwell. This occurs about 3-4 times/week. He had a gastric bypass about one year ago.
Snacks on ++ chocolate covered raisins at PM snack.
Symptom onset between PM snack and dinner.
No glucometer.
Usually constipated but has diarrhea after PM snack.

A 
Rule out: hypoglycemia and its source 
Investigate:
- Onset of symptoms as related to last meal/snack 
- Type of food consumed
- Diarrhea?
Likely dumping syndrome.
Nutrition Intervention:
- Healthy snacking
- Avoidance of trigger foods (limiting simple sugars) 
- Label reading (≤25 g absorbable carb)
35
Q

Describe dumping syndrome

A

Occurs with RYGB, due to the removal of the pyloric sphincter.

2 phases:
1. “Early” phase:
- Occurs 10-30 min PC
- Due to rapid transit of hyperosmotic food into the jejunum (usually simple sugars)
Symptoms: dizziness, nausea, weakness, rapid pulse, diarrhea

  1. “Late” phase
    Occurs 1 – 3 hours PC
    Reactive hypoglycemia due to an exaggerated release of insulin.
36
Q

A 42 y.o. man reports symptoms of shakiness, sweats, nausea, and feeling very unwell. This occurs about 3-4 times/week. He had a gastric bypass about three years ago.
Symptom onset between PM snack and dinner.
High carb, low protein lunch and PM snack.
Possibly nesidioblastosis (hyperinsulinemic hypoglycemia).

A

Nutrition Intervention:

  • Increase protein:carb ratio at lunch and PM snack.
  • If no change in symptoms, to see an endocrinologist.
37
Q

A patient had bariatric surgery (any procedure) 4 months ago and complains of hair loss.
Is hair loss always a sign of poor protein intake?

A
  • No. Consider ‘shock loss’ (telogen effluvium), the thinning or shedding of hair due to physiological stress of surgery.
  • Occurs between 3 - 6 months post-op (early hair loss).
  • Reassure patient and encourage adequate protein intake and vitamin compliance.
38
Q

symptoms of zinc deficiency:

A

Hair loss

Dysgeusia

39
Q

Consider zinc deficiency if + intervention

A
  • Hair loss begins > 6-9 months post-op
  • Attaining est protein needs, and
  • Insufficient zinc supplementation

Nutrition Intervention:

  • Zinc supplementation: 60 mg elemental BID
  • Monitor plasma zinc in bloodwork
  • Suggest complete multivitamin to patient considering:
  • Palatability, ease of swallowing pills, and cost to patient.
40
Q

A patient returns to see you 14 months after her bariatric surgery. She has regained 25 lbs. She reports she is constantly hungry and she can tolerate a lot more food that she used to, and she is very discouraged.

A

How can you explain this?
You review her dietary habits and identify that she has been drinking fluids with her meals.

Nutrition Intervention:
Educate pt on the reason for delaying fluids and its
consequences. Suggest tips to make this easier for the pt.

41
Q

A patient regained 60 lbs. You have previously reviewed all the dietary habits that needed modification and, via motivational interviewing, the patient has set some small goals for lifestyle change.

1 month later: +6 lbs despite having made some dietary changes.
2 months later: + 7 lbs; she reports ++ grazing when she is stressed, bored,
and angry.
What do you do?

A

Suggest the benefits of seeing a psychologist for better management of her emotions. Dietary counselling has not provided a solution to her emotional eating thus far. Refer her and offer continued dietary support to encourage positive changes. Keep in contact with psychologist.

42
Q

A patient is admitted to the hospital ward that you cover. She has been diagnosed with an anastomotic leak.
- Most feared surgical complication (fatal)
- Occurs at suture lines
- Gastric contents leak into abdomen
What would your nutrition care plan be?

A
  • TPN – total parenteral nutrition

- Why not enteral feeds? Bowel needs to be at rest to encourage the healing process.

Clinical 3 (17 decks)

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