Metabolic Surgery -Safaoui

Question 1

What is the BMI classification for Obesity?

Answer 1

30-34=obese

35-49=severely obese

> 50=superobese

Question 2

What is the safest route to lose weight? Who is this ineffective for?

Answer 2

Medical treatment

Ineffective for severely obese people who must lose 75 + lbs.

Question 3

What are the risk factors that increase the risk of postop comorbidities in bariatric surgery?

Answer 3

of comorbidities present preoperatively:

• BMI of >50
• Male gender
• Hypertension
• Presence of risk factors for pulmonary embolism
• Age >45

*2 or more of these factors will increase the patient’s mortality

Question 4

What are the indications for bariatric surgery?

Answer 4

-BMI ≥40 with or without comorbid medical conditions.
-BMI of 35-40 with comorbid medical conditions.
-Patients must also
Failed attempt at other weight loss treatments (medically supervised diet)
-Be psychologically stable

Question 5

What are some relative contraindications for bariatric surgery?

Answer 5

• Inability or unwillingness to change lifestyle postoperatively
• Substance addiction
• Inability to ambulate
• Noncompliant
• Unsupportive home and family environment
• Psychologically unstable

*most common=inadequate insurance coverage

Question 6

What is Laparoscopic Adjustable Gastric Banding? What kind of procedure is this? Who is this best for? not as effective in?

Answer 6

• Restrictive procedure
• Placement of an inflatable silicon band around the proximal stomach–>reservoir to adjust the tightness
• best for older, more medically ill or higher-risk pts
• not as effective in super obese

Question 7

Who are poor candidates for LAGB (gastric banding)?

Answer 7

• impatient to lose weight
• immobile
• unwilling to exercise
• grazers/niblers -hx of previous gastric surgery

Question 8

*what is the most common complication of LAGB? How does it present? How is it diagnosed?

Answer 8

Prolapse–> stomach is trapped in band

present with dysphagia, vomiting, inability to tolerate solids and liquids

dx by X-ray or upper GI

Question 9

What is a Laparoscopic Roux-en-Y Gastric Bypass (LRYGB)? What type of procedure is this? What is bypassed?

Answer 9

• Restrictive > Malabsorption
• *most common bariatric procedure
• Part of the stomach is cut creating a gastric pouch (<20mL) and then attached to the roux limb of the proximal jejunum
• bypasses some of the stomach and the duodenum

Question 10

What are the nutritional complications associated with LRYGB?

Answer 10

• Iron deficiency in 20 to 40% of patients
• Iron deficiency anemia in 20%
• Vitamin B12 deficiency in 15%
• Vitamin D deficiency in at least 15%

Question 11

*What is the most lethal complication of LRYGB?

Answer 11

-Small-bowel obstruction:
From an internal hernia due to inadequate closure or nonclosure of the mesenteric defects created during surgery.
-Requires surgery on an emergent basis

Question 12

*What is the most feared complication of LRYGB?

Answer 12

-Anastomotic leak

• presents with tachycardia, tachypnea, fever and oliguria
• requires emergent surgery or they could DIE if left untreated

Question 13

What is a biliopancreatic diversion (BPD) and duodenal switch (DS)? What type of procedure is it? How often is it done?

Answer 13

• mostly malabsorptive (food does not go through the jejunum or ileum)
• not done frequently–> highest rate of morbidity and mortality

BPD:

• distal subtotal gastrectomy w/ a 200 cc gastric pouch.
• terminal ileum is divided 250 cm before the ileocecal valve
• distal terminal ileum is anastomosed with the residual stomach.
• The proximal end of the ileum is then anastomosed side-to-side to the terminal ileum approximately 100 cm proximal to the ileocecal valve.
• Prophylactic cholecystectomy

DS:

• sleeve gastrectomy
• duodenum divided in its first portion
• distal end anastomosed to the distal ileum

Question 14

When is a biliopancreatic diversion and duodenal switch (BPD) performed? What are some SE?

Answer 14

• Superobese
• Failure of previous restrictive operation who are considering reoperation
• Can’t follow diet and exercise plan that are important in a restrictive operation

SE:

• diarrhea with every oral intake (may not always make it to the bathroom)
• must be followed closely
• have to afford the vitamin and mineral supplements ($1500/year)

Question 15

What are some contraindications for the biliopancreatic diversion and duodenal switch (BPD)?

Answer 15

• Geographically far from surgeon
• Lack of resources to afford supplements
• Pre-existing deficiencies of calcium, iron, or other vitamins or minerals.

Question 16

What is the most common and concerning complication of biliopancreatic diversion and duodenal switch?

Answer 16

Nutritional —> protein malnutrition’s the most severe and life-threatening

Question 17

What is a sleeve gastrectomy? What type of procedure is this? What is the patient selection?

Answer 17

• Removal of the stomach leading only a banana size amount
• restrictive
• patient selection:
• high-risk pts considering the DS operation (Cardo and plum problems, old, anesthesia problems)
• desire for a restrictive procedure without a foreign body

Question 18

What comorbidity does the sleeve gastrectomy NOT treat?

Answer 18

GERD

Question 19

What is the most common complication of the gastrectomy sleeve? Where does this normally occur?

Answer 19

anastomotic leak

normally at the proximal staple

Question 20

What is the #1 cause of postoperative death?

Answer 20

PT

20-30% mortality
-high risk with BMI > 55 or previous DVT
==> may need an IVC filter

Question 21

How do vagal stimulators work?

Answer 21

stimulate the neural input to the stomach –> dec appetite and stimulate early satiety and weight loss

Question 22

What is an intragastric balloon used for? What are the complications?

Answer 22

Short-term bridge to weight loss to be followed by a more definitive procedure.

High incidence of balloon migration and bowel obstruction.