Bariatric Surgery And Metabolic Syndrome Flashcards
Obesity definition
Defined as a body mass index > 30kg/m2
What is the only effective intervention for morbid obiesty that consistently induces sustained weight loss?
Bariatric surgery
*the results of just bariatric surgery are better than those with a combination of diet/exercise and behavioral modifications with weight loss drugs**
Inclusion criteria
- BMI greater than 40 kg/m2
- BMI greater than 35 kg/m2 with OSA, cardiomyopathy or severe DM
- have failed multiple non surgical weight loos attempts
Contraindications
- mental or cognitive impairment (mental disorders or extreme Durgs/alcohol use)
- unstable CAD
- advanced liver disease
- active Crohn’s or UC
What are the most common bariatric surgery procedures
1) Roux-en-Y gastric bypass (old #1)
- use to be gold standard
2) laparoscopic adjustable gastric banding
3) laparoscopic sleeve gastrectomy (new #1)
- is now the gold standard
What should be done before bariatric surgeries?
1) identify any current nutritional deficiencies or necessary dietary interventions that will be needed
2) develop a plan for behavioral modification in dietary intake
3) psychological assessment
- get a detailed substance abuse history
Diabetes mellitus as a comorbidity to bariatric surgery
More than 90% of type 2 diabetics are overweight or obese
In order to go for bariatric surgery, the ASMBS requires diabetics to have an A1C value less than 6.5-7.0% or less. Also
- a fasting blood glucose less than or equal to 110 md/dL
- 2hr postprandial blood glucose concentration of <140 mg/dL
Obstructive sleep apnea
Incidence is higher in obesity (as high as 78%)
- should be expected in history of loud snoring, frequent nocturnal awakening
What cardiac disease syndromes can be predictors of possible peri operative cardiac events occurring?
Unstable coronary syndromes
Acute or recent myocardial infarction
Ongoing ischemic heart disease
High grade AV blocks
Valvular disease
because of this, before doing bariatric surgery get an ECG on all obese patients >30 rays of age
What is the leading cause of death after bariatric surgery?
VTE events or cardiac arrythmias (tie)
- in patient’s at high risk for VTEs, prophylaxis IVC filter may be placed
- every patient post op bariatric surgery should walk around a lot to help protect agaisnt this
What is often administered after Roux-en-Y surgery to prevent gallstones?
Ursodeoxycholic acid 300mg orally 2x daily
- normally 25-40% risk fo getting gallstones; with this acid = 2% only
if the patient already has gallstones and is about to undergo bariatric surgery = may take out the gallbladder (cholecystectomy)
What can be done to help obese patients undergoing bariatric surgery to not get negative side effects from anesthesia?
Volume ventilators
Placing the patient in reverse trendelenburg position (expands total lung volume)
Laparoscopic adjustable gastric band (LAGB)
Introduced in 1993 and is rather easy to do with low mortality and morbidity
essentially ties a gastric band around the opening of the stomach around the angle of his and through the pars flaccida
DOES have high complications however and often needs revision ACL surgery so has fallen out of favor as a first line therapy
- 43% complication risk with the most common being band slippage and stomach dilation
- 7.2-60% reoperative rates
Other complications
- perforation
- stomach obstruction
- gastric obstruction
- gastric prolapse
- esophageal or pouch dilation
- gastric erosion
- dysphagia due to vagus nerve damage
- spleen issues
Laparoscopic Roux-en-Y-Gastric bypass (LRYGB)
One of the most popular bariatric surgical procedures with significant variation between surgeons
Is a restrictive and malabsorption procedure
Steps:
1) creation of a gastric pouch
- resect the stomach about 4-5cm distal to the gastroesophageal junction but stay caudally to the left gastric artery
2) induce gastrojujunostomy
3) induce jejunojejunostomy
4) close the mesenteric defect at #3 site
**40% chance of patients post op of a LRYGB seeing a A1C if less than 6%
Mortality rate = 2%
- complication rate = 10%
Most common complications are
- bowl obstruction secondary to internal hernia (“Peterson hernia”)
- stenosis of the gastrojejunostomy anastomosis
- nutritional deficiency
- marginal ulcers at the gastrojejunostomy site (treat with omental patch)
- irreversible
- summoning syndrome
- excessive common duct gall bladder stones secondary to weight loss (need to remove gallbladder to prevent this**)
must be careful of intra-abdominal sepsis signs post-op (hypotension, abdominal pain, tachycardia, etc)
Laparoscopic sleeve gastrectomy (LSG)
Originally was conceived as a restrict part of another surgery, but now is sort of first line in bariatric surgery
Is rather easy to do an short learning curve but also has less complications
- *ABSOLUTE contraindication = Barrett esophagus**
- relative = GERD
Technique essentially requires excising a large portion of the stomach (greater curvature and most of the fundus and cardia) and create a “sleeve”from esophagus to duodenum
- if any hiatal hernia is present, also will be fixed at this time
leads to substantial drop in grueling levels = BE CAREFUL for anorexia
What signs after a LSG should be concerning and require immediate operative intervention?
Tachycardia and fever = may be leak
- if this is true = convert to a gastric bypass
What is BPD/DS?
Biliopancreatic diversion with or without duodenal switch
- essentially combines a sleeve gastrectomy with a duodenoileal switch
Cuts out most of the stomach
Cuts the duodenum before the biliary and duodenal papillae and then reattached the duodenum to the distal ileum
- the purpose of this is to prevent pancreatic and biliary enzymes to mix with chyme so that fat doesnt get absorbed
Results in excellent long-term weight loss and highest levels of improvement in T2DM, Hypercholesterolemia, OSA, HTN
- ONLY done in super morbidly obese (>40 BMI)
HOWEVER complications are
- DEAK malanbsoption
- vitmain B12 deficency
- mega esophagus
- dumping syndrome
- etc.
has a decent amount of complications
What cancers are higher in morbidly obese patients?
Breast
Ovarian
Endometrium
Pancreas
Prostate
Colon
Liver
What is a “yo-yo” diet?
Crash cart like diets in obese patients
- results in weight loss and then immediate weight gain back once they stop the diet/cant do it anymore
- *yo-yo actually slowly increases weight overall**
- the only true way to lose weight without it coming back is “slow and steady” with behavioral modification
What are the most common comorbidities that bariatric surgery improves?
Hyperlipidemia
- 70% corrected
Essentially hypertension
- 70% corrected
OSA
- 80% corrected
T2DM
- 90% corrected
GERD = usually resolved (except in sleeve where it is a contraindication to this procedure)
Back and joint pain as well as venous embolic disease is improved with varying amounts
What is the most severe psychological complication for bariatric surgery?
Suicide
- 58% higher
What is the respiratory quotient?
RQ = CO2 eliminated/O2 consumed
- can be measured with a metabolic cart
The RQ that is present at anytime in a patient can tell you what you are currently burning right now
- carbohydrates = 1
- proteins = 0.8-0.9
- ketones = 0.66-0.73
- *caloric equivalents**
- carbohydrates = 3.4 kcal/g
- protein = 4 kcal/g
- fat = 9 kcal/g
Which bariatric procedures are malabsorptive vs restrictive
Malabsorption = limits the amount of nutrients the GI tract can take in. Includes:
- jejuni-ileal bypass
- billio-pancreatic diversion with duodenal diversion/switch
- gastric bypasses
- BPD/DS
Restrictive procedures = limits overall area of the stomach/GI tract. Includes
- vertical banded gastroplasty
- sleeve gastrectomy (is both restricted and malabsoptive)
- gastric ballon and banding
- roux-en-y (is both restrictive and malabsorption)
- laparoscopic banding
What are the most common nutritional deficiencies in bariatric surgery patients?
Protein
Iron
Folate
B12
- peripheral neuropathy
Thiamine (B1)
- peripheral neuropathy
Fat soluble (DEAK) - most common
What predisposing factors increase risk for peripheral neuropathy after bariatric surgery?
Rapid weight loss in post op
Severe protracted vomiting
What surgery did Edward mason develop?
Vertical-banded gastroplasty (VBG)
- this is one of the first bariatric surgery procedures, however it is not used much anymore because it has mass amounts of complications
What is the gastric bypass surgery?
Bypasses the stomach completely and moves from esophagus -> jejunum
Is a combination of restrictive and mal absorptive procedures
Initial complications
- regain weight
- iron deficiency
- loss of intrinsic factor
- dumping syndrome
dumping syndrome = flush, nausea, diarrhea due to excessive consumption of carbohydrates that ignore the stomach and get through the intestines before proper digestion
Petersen hernia
A internal defect in the mesentery
- floppy mesentery from rapid weight loss results near the gastrojejunostomy
- results in intestinal loops to herniate through this site and get squeezed by the mesentery
Is the most lethal complication in a roux-en-y gastric bypass
Shows abdominal discomfort, fever, tachycardia and potentially POOP (but not always)
- CT scan doesn’t always show this
if not corrected, small intestines that are herniated necrosis and die
What are generalized early and late complications of all bariatric surgeries
Early complications
- nausea/vomiting
- dyspnea
- tachycardia and arrhythmias
- VTEs
- bruises
- anasomotic complications (obstruction, bleeding, leaks, etc)
Late complications
- osteoporosis
- cholelithiasis and choledocholithiasis
- nephrolithiasis
- hernias
- gout
- fistulas
- PUD and increased susceptibility to H. Pylori infections
- bowl obstruction
Gastric balloon
Place a plastic ballon in the-stomach which causes it to feel physiologically full quicker
Causes excessive HCL (high high risk for PUD) and gastrin release and can also obstruct the entire stomach (mass vomiting)
- NOT 1st line at all today
also compresses the pancreas resulting in acute pancreatitis
What is a gastric pacing procedure?
Used in DM type 1 and 2 gastroparesis
- DM type 1 and 2 can cause dysfunction in the autonomic nervous system of the stomach. Causes flaccid vagus nerve
This results in stomach engorging/distended and inability to empty properly
To fix this = put a pacemaker on the stomach to attempt to restore the stomach nervous system
- *minimal to no morbidity and the only real risk is dislodgement of the battery**
- results are highly variable
What hormones are disabled from gastric bypass surgery?
Ghrelin
GALP-1
Peptide YY (PYY)
Glucose-dependent insulinotropic polypeptide (GIP)
Leptin
