Metabolic Surgery -Safaoui Flashcards
What is the BMI classification for Obesity?
30-34=obese
35-49=severely obese
> 50=superobese
What is the safest route to lose weight? Who is this ineffective for?
Medical treatment
Ineffective for severely obese people who must lose 75 + lbs.
What are the risk factors that increase the risk of postop comorbidities in bariatric surgery?
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
What are the indications for bariatric surgery?
-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
What are some relative contraindications for bariatric surgery?
- 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
What is Laparoscopic Adjustable Gastric Banding? What kind of procedure is this? Who is this best for? not as effective in?
- 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
Who are poor candidates for LAGB (gastric banding)?
- impatient to lose weight
- immobile
- unwilling to exercise
- grazers/niblers -hx of previous gastric surgery
*what is the most common complication of LAGB? How does it present? How is it diagnosed?
Prolapse–> stomach is trapped in band
present with dysphagia, vomiting, inability to tolerate solids and liquids
dx by X-ray or upper GI
What is a Laparoscopic Roux-en-Y Gastric Bypass (LRYGB)? What type of procedure is this? What is bypassed?
- 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
What are the nutritional complications associated with LRYGB?
- 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%
*What is the most lethal complication of LRYGB?
-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
*What is the most feared complication of LRYGB?
-Anastomotic leak
- presents with tachycardia, tachypnea, fever and oliguria
- requires emergent surgery or they could DIE if left untreated
What is a biliopancreatic diversion (BPD) and duodenal switch (DS)? What type of procedure is it? How often is it done?
- 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
When is a biliopancreatic diversion and duodenal switch (BPD) performed? What are some SE?
- 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)
What are some contraindications for the biliopancreatic diversion and duodenal switch (BPD)?
- Geographically far from surgeon
- Lack of resources to afford supplements
- Pre-existing deficiencies of calcium, iron, or other vitamins or minerals.
What is the most common and concerning complication of biliopancreatic diversion and duodenal switch?
Nutritional —> protein malnutrition’s the most severe and life-threatening
What is a sleeve gastrectomy? What type of procedure is this? What is the patient selection?
- 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
What comorbidity does the sleeve gastrectomy NOT treat?
GERD
What is the most common complication of the gastrectomy sleeve? Where does this normally occur?
anastomotic leak
normally at the proximal staple
What is the #1 cause of postoperative death?
PT
20-30% mortality
-high risk with BMI > 55 or previous DVT
==> may need an IVC filter
How do vagal stimulators work?
stimulate the neural input to the stomach –> dec appetite and stimulate early satiety and weight loss
What is an intragastric balloon used for? What are the complications?
Short-term bridge to weight loss to be followed by a more definitive procedure.
High incidence of balloon migration and bowel obstruction.
