MININVASIVE / OBESITY Flashcards
physiologic effects of CO2 pneumoperitoneum
kidney
Heart
Acid base
decreased glomerular filtration rate decreased urine output Increased renin Increased ADH careful, Increased serum cortisol Decreased stress mediated hormone Decreased immune suppression Careful, respiratory acidosis Increase systemic vascular resistance Increased blood pressure Increased myocardial oxygen demand Most common arrhythmia his bradycardia-rapid stretch peritoneal membrane causes vasovagal bradycardia and hypotension But, hypercarbia also causes tachycardia and increased vascular resistance
effects of N20 pneumoperitoneum
increase analgesia
no increased flammability
Reduced intraoperative end-tidal CO2 and minute ventilation
Safety not known with pregnancy or cancer
how does laser therapy restored luminal patency and blood vessel
core out
risk factor for creating air embolism during laparoscopy
using poorly soluble gas:
Helium
Neon
Argon
Signs of gas emboli during laparoscopy
Hypotension during insufflation
mil wheel murmur
Treatment of gas air embolism during laparoscopy
Left lateral decubitus
Trendelenburg
Possible central venous catheter to aspirate catheter gas out of right ventricle
capacitive coupling
plastic trocar to inflate abdominal wall from the current and the current comes off metal sleeve or the chest laparoscope into the viscera
weeks pregnant for the uterus to reach the umbilicus
20
Pregnant positioning for laparoscopy
left lateral decubitus
Argon beam during laparoscopy
monopolar uniform field of electronic distributed across the tissue surface by use of argon gas jet
more even superficial coagulation
Increased intra-abdominal pressure
Increased gas embolism
what causes of obesity
genetics
Environment
Lack of satiety
calorie deficit required to lose 1 pound per week
3500
Daily dose of 500 calories
Classifications of obesity by BMI
underweight less than 18.5 Normal weight 20- 24.9 Overweight 25-29.9 Obese 30 or greater class I obese 30-34.9 class II obese 35-39.9 Class III obese MORBID 40 or greater
criteria for bariatric surgery
BMI 40 old with prolonged we made all the air there and I now it is all floor is a blue then a who is a and B. and he is a
BMI 35 with comorbidities
BMI 30 with uncontrolled diabetes
must have attempted diet control
Contraindications:
psychiatric
Drug abuse
Ability to comply
obesity related comorbidities that are predictive of mortality
5 factors: 1 BMI greater than 50 2 Male 3 Hypertension 4 Risk factors for pulmonary embolism 5 Age greater than 45
2 or more factors increased patient mortality
contraindications for gastric bypass surgery
Psychiatric
Drug abuse
Ability to comply
neurologic pathology associated with obesity
pseudotumor cerebri
Cancers associated with obesity
uterine
Breast
Colon
Prostate
NOT liposarcoma
percentage of a morbidly obese patient able to successfully lose weight and maintain that weight with diet and exercise
less than 5%
Morbid obesity is 40 or greater BMI
Using prescription weight loss drugs to treat
obesity is an option for the following people:
People with a body mass index(BMI) of 30 or above People with a BMI of 27 or above with obesity-related conditions, such as diabetes or high blood pressure
Most weight loss drugs are for short-term use, meaning a few weeks or months.
weight loss drugs
phentermine FDA approved - controlled substance
Belviq FDA approved - controlled substance
appetite suppressant for long-term use in treating obesity.
Side effects include dizziness, headache and tiredness.
Qsymia FDA approved - controlled substance
combines phentermine with the seizure/migraine drug topiramate.
Topiramate causes weight loss in several ways, including increasing feelings of fullness, making foods taste less appealing, and increasing calorie burning.
designed to be taken long-term.
contraindications:
pregnant women
glaucoma
hyperthyroidism.
not recommended for people with recent or unstable heart disease or stroke.
Orlistat FDA approved-over-the-counter
Orlistat works by blocking about 30% of dietary fat from being absorbed.
Orlistat is available by prescription as Xenical and over-the-counter as Alli.
Xenical is moderately effective, leading to a 5% to 10% weight loss when taken along with a low calorie/low-fat diet. Most of the weight loss happens in the first six months.
most common emergent complication of laparoscopic adjustable gastric band
Prolapse
Vomiting may contribute to this complication
Lower stomach could become pushed upward and trapped within the lumen of the band
Highlights of Roux-en-Y gastric band technique
gastric pouch 20 mL
Biliopancreatic limb from the ligament of Treitz to distal enterostomy is 20-50 cm
Length of Roux limb 75-150 cm with good
recommended management of patient’s with negative ultrasound for gallstones undergoing Roux-en-Y gastric bypass
ursodiol postoperatively
if positive gallstones concomitant cholecystectomy or delayed cholecystectomy asymptomatic
relative Contraindications to laparoscopic Roux-en-Y gastric bypass
previous gastric surgery
Previous antireflux surgery
Severe iron deficiency anemia
Distal gastric or duodenal lesions requiring ongoing future surveillance
Barrett’s esophagus with severe dysplasia
What percentage of excess body weight patient’s lose in the first year after Roux-en-Y gastric bypass
60-70%
Resolution of comorbidities after Roux-en-Y
diabetes mellitus GERD Venous ulcers Hyperlipidemia was Hypertension
management of patient one year out from Roux-en-Y with small bowel obstruction on CT scan who is stable
Emergent laparotomy or laparoscopy
Management of marginal ulcer after Roux-en-Y
PPI only
Surgical therapy for:
Gastric gastric fistula
Severe stenosis of gastric J.
Nonhealing ulcer
Major steps of biliopancreatic diversion
resect the distal half to two thirds of stomach-pylorus-preserving
the last 200 cm of ileum is anastomosed to the stomach
and the biliary pancreatic drainage limb is anastomosed 75-100 cm proximal to the ileocecal valve
The small bowel is then transected 250cm from the ileocaecal valve.
The biliary limb is anastomosed to the ileum to create a 100cm common channel. The alimentary limb is anastomosed to the duodenum using a hand-sewn technique to create a 250cm alimentary channel.
way to the difference between pancreatic diversion alone and duodenal switch
only the smaller proximal gastric remnant to the
2 most common deficiencies after Roux-en-Y
vitamin B12 deficiency
Iron deficiency anemia most common deficiencies
syndrome X.
central obesity
Glucose intolerance
Dyslipidemia
Hypertension
Increased risk of developing coronary artery disease and diabetes
Most common complication after biliopancreatic diversion
anemia 30% Protein calorie malnutrition 20% Dumping syndrome and marginal ulcer 10% B12 deficiency Hypocalcemia fat soluble vitamin deficiency Osteoporosis night blindness Prolonged PT
Advantages of duodenal switch in addition to biliopancreatic diversion
lower marginal ulcer rate
Lower dumping syndrome is
