Lecture 12: Bariatrics & Hernias Flashcards
Which hormone is known as the satiety hormone? Where is it produced?
Leptin - produced in adipose tissue, inhibits hunger
How is leptin altered in obesity?
Increased production but decreased sensitivity - dont feel full
Which hormone is known as the hunger hormone because it stimulates hunger? Where is it produced?
Ghrelin - (stomach goes Grrr when hungry)
- produced in fundus
How does Ghrelin differ from Leptin?
Ghrelin opposes Leptin and it doesn’t affect satiety
How does insulin affect leptin?
insulin blocks leptin in the brain causing increased hunger
What hormone increases satiety?
Peptide YY
What hormone increases insulin sensitivity and decreases energy storage and hunger?
GLP-1
What are the top 2 consequences of obesity?
- DM
2. HTN
What is obesity the single most reliable predictor of?
Type 2 DM
For each 1% of body wt lost, how is your DBP and SBP affected?
lose 1% body wt:
- 1 mm Hg decrease in DBP
- 2 mm Hg decrease in SBP
For BMI >35 what is the only method for sustained wt loss?
Surgery
note: surgery is ToC when BMI > 40
Bariatric surgery is what type of wound classification? And therefore what ABX should be used?
Clean contaminated - use Cefazolin or Clindamycin
What are the components of the NIH criteria for bariatric surgery?
- BMI > 40 or BMI > 35 + comorbid illness
- Hx of failed sustained wt loss on a supervised wt reduction program
- No substance abuse, psychoses or uncontrolled depression
What is the purpose of malabsorptive bariatric procedures? Example?
They shorten the digestive tract
Ex: BPD
What is the purpose of restrictive bariatric procedures? Examples?
Reduce the amount of food the stomach can hold
Ex: Sleeve Gastrectomy, Gastric Band surgery
What is the gold standard bariatric procedure?
Sleeve gastrectomy
What parts of the stomach are kept and removed in Sleeve gastrectomy? Results in?
Keep antrum - limits food intake
Remove fundus
Result: smaller stomach –> produce no ghrelin, faster transit time –> more insulin sensitivity & satiety
Advantages of sleeve gastrectomy?
what is the main disadvantage?
- Laproscopic
- **No rerouting of GI tract (no defic)
- **Eliminate hunger hormone
- Fewer complications than bypass
- Fairly rapid initial wt loss
Disadv: NOT reversible
What is done during Gastric Banding? Result?
Band is placed around stomach –> limits food intake & promotes satiety but DOES NOT decrease hunger
Advantages of Gastric Banding?
- **LOWEST mortality/complication rate, least invasive
(No rerouting, stapling, or cutting) - **AJUSTABLE & REVERSIBLE
- Low malnutrition risk
Disadvantages of Gastric Banding?
- **Need regular adjustments & f/u
- **Limited applications (low BMI, not long term)
- High long term failure rate
- Requires implanted device
- Slower wt loss initially
Complications of Gastric Banding?
- Obstruction
- Dilatation of pouch/esophagus
- Band displaces
- Food intolerance
- Erosion - may cause infection
- Leak
- Failure to lose wt & can regain it
What is the purpose of combined bariatric procedures? Examples?
Shorten the GI tract and reduce amt of food the stomach can hold
Ex: BPD/Duodenal switch, Roux-en Y Gastric Bypass
Advantages of BPD/Duodenal switch?
- **Most wt loss overall
- **Most effective vs DM
- **Incr satiety AND decr hunger
- Can eat normally
- No dumping syndrome
- decr fat absorption
Disadvantages of BPD/Duodenal switch?
- **more complications/risk
- **Deficiences (protein, Vitamins, minerals)
- longer LOS
Complications of BPD/Duodenal switch?
Anemia, osteoporosis, kidney stones, malnutrition
How is Roux-en Y Gastric Bypass done?
Advantages of Roux-en Y Gastric Bypass?
Stomach stapled, small bowel re-routed
- **Most effective vs GERD
- **Rapid wt loss initially w/out changing diet
Disadvantages of Roux-en Y Gastric Bypass?
- Re-routing –> defic
- **Dumping Syndrome
- More operative complications, may need revision
Complications of Roux-en Y Gastric Bypass?
- Leaks
- ulcers
- hernias
- bowel obstruction
- Wt regain
What procedure is associated w/Dumping Syndrome?
Roux-en Y Gastric Bypass
What procedure is most effective against DM?
BPD/Duodenal Switch
What procedure eliminates the hunger hormone?
Sleeve gastrectomy
What procedure has lowest mortality & complication rate and is least invasive?
Gastric Banding
What procedure is most effective against GERD?
Roux-en Y Gastric Bypass
What are causes of acquired hernias?
- Increased intra-abdominal pressure
- Older age –> weakened fascia
- Tissue injury
What are the causes of congenital hernias?
- Fascial opening that doesn’t close
2. Failure of a developmental process to obliterate
Where is the inguinal canal located?
Beneath the external oblique aponeurosis
What are the boundaries of Hesselbach’s triangle?
Base: inguinal ligament
Lateral border: inferior deep epigastric vessels
Medial border: rectus muscle
How does a direct hernia differ from an indirect hernia in regards to location/contents/risks?
Direct
- MEDIAL to inferior epigastric vessels
- NO peritoneal sac
- low risk of incarceration
Indirect (MC)
- LATERAL to inferior epigastric vessels
- Peritoneal sac
- high risk of incarceration/strangulation
Where do femoral hernia develop?
in the femoral canal - BELOW the inguinal ligament and MEDIAL to the femoral vein
What are femoral hernia’s often mistaken with?
Cloquet’s node - proximal deep inguinal node NEXT TO (not w/in) the femoral canal
How do hernias present?
- LUMP (worsen w/activity, strain, cough, sneeze)
- Pain w/exertion or straining
- Complication (Bowel obstruction)
How do you Dx a hernia?
US or CT
CT better for ventral, incisional, traumatic hernias & atypical presentations
Do hernias typically need treated w/ABX?
No - clean cases (only do if having surgery)
- What is the treatment for minimally symptomatic hernias?
2. When is urgent surgical correction needed?
- Observation
2. When theres sign of non-reducible incarceration/strangulation
Complications associated specifically w/hernias?
- Urinary retention (esp males w/groin hernias)
- Hernia recurrence (worst if no mesh and open)
- Seroma (dont aspirate early)
How do you prevent urinary retention associated w/hernias?
Restrict peri-op fluids
