Gastric Bypass Surgery and Sleeve

Question 1

Indications for bariatric surgery

Answer 1

BMI >40

BMI >35 with medical comorbidity

Question 2

BMI calculation

Answer 2

kg/m2

or roughly: (wt x 703)/in2

Question 3

Options for surgical weight loss

Answer 3

Gastric bypass (best)
Sleeve

Question 4

Parts of gastric bypass

Answer 4

Stapling off pouch (restrictive)

Roux-en-Y limb to gastic pouch (bypass)

Question 5

Mech of bypass:

Answer 5

1. Small gastric reservoir
2. Intentional dumping when overeats - dumped into Roux-en-Y limb
3. Bypass of small bowel by limb

Question 6

Postoperative complications

Answer 6

Gallstones
Anastomotic leak (3%)
Marginal ulcer (.6-16%)
Stenosis (6-20%)
Incisional hernia
Reminant distension

Dumping syndrome
Malnutrition
Iron def
B12 def

Question 7

Most common sign of leak after surgery?

Answer 7

Tachycardia

Question 8

Incidence of anastomotic leak

Answer 8

~3% (1-5%)

Question 9

Mortality rate with anastomotic leak

Answer 9

10%

Question 10

Define Petersen’s hernia

Answer 10

Internal herniation of small bowel through mesenteric defect from roux-en-Y limb (specifically at the transverse mesocolon)
Possiblity of SBO d/t defect is 3-5% lifetime

Question 11

Ventral incision hernia risk (laproscopic)

Answer 11

0-1.8%

Question 12

Ventral incision hernia risk (open)

Answer 12

Up to 26% (30% per Dr. Roller, all comers)

Question 13

Post-op bypass stenosis:
rate
def
tx

Answer 13

6-20%
Lumen <10mm
Tx with balloon

Question 14

Post-op bypass gallstones: rate

Answer 14

Up to 38% w/in 6 months
Rapid weight loss leads increasing lithogenicity of bile
Ppx ursodeoxycholic acid decreased to 6%

Question 15

Dumping syndrome (early)

Answer 15

W/in 15 minutes of eating
High simple carb/amount
Fluid shifts in -> dumping
Colicky pain, nausea, diarrhea, tachy

Question 16

Dumping syndrome (late)

Answer 16

Aka postprandial hyperinsulinemic hypoglycemia (PHH)

Up to 0.3%, 1-3 hours after meal, years after surgery

Question 17

B12 deficiency

Answer 17

Up to 1/3 of patients
Pathophys: inadequate gastric acid available (less intrinsic factor activation) and less intrinsic factor (less parietal cells)
IF-B12 absorbed in terminal jejunum

Question 18

What is the ligament of tritz?

Answer 18

Remanent of middle bowel looping in embryology

Marks end of duodenum and beginning of ileum

Question 19

Causes of marginal ulcers

Answer 19

Poor tissue perfusion
Foreign material near anastomosis
Acid exposure
NSAID use
H pylori infection
Smoking

Question 20

Marginal ulcer complication rate

Answer 20

0.6-16%