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A1-G Surg Note Stomach > Morbid Obesity > Flashcards

Morbid Obesity Flashcards

1
Q

What BMI qualifies a patient for bariatric surgery, regardless of comorbidities?

A

A BMI of 40 kg/m² or greater

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2
Q

What BMI range qualifies a patient for bariatric surgery if obesity-related comorbidities are present?

A

A BMI between 35 and 40 kg/m², with conditions such as diabetes or hypertension.

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3
Q

According to the ASMBS, when should bariatric surgery be considered for patients with class I obesity (BMI 30–35 kg/m²) and comorbidities?

A

After failure of nonsurgical treatment methods, and it should be strongly considered for patients with type 2 diabetes

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4
Q

What alternative treatments may be considered for patients with a BMI of 30 to 40 kg/m² who cannot undergo bariatric surgery?

A

Intragastric balloon (IGB) or endoscopic sleeve gastroplasty (ESG).

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5
Q

Why might a patient choose IGB or ESG over bariatric surgery?

A

Due to contraindications for surgery (e.g., hostile abdomen, large ventral hernia) or unwillingness to undergo surgery despite understanding its effectiveness

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6
Q

What should candidates for bariatric surgery demonstrate before surgery is considered?

A

Prior attempts at nonsurgical weight loss options, including dietary interventions, pharmacologic therapy, or behavioral modifications.

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7
Q

relative contraindications for bariatric surgery?

A

Inability to comply with postoperative requirements, active alcohol or substance abuse, and uncontrolled psychiatric disease

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8
Q

What is the recommended approach to evaluating candidates for bariatric surgery

A

A multidisciplinary team approach

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9
Q

Which professionals should be included in the bariatric surgery evaluation team?

A

A dietician and a mental health professional with experience in bariatric surgery

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10
Q

What is a staged operation in bariatric surgery?

A

It involves performing a laparoscopic sleeve gastrectomy first, followed by a Roux-en-Y gastric bypass or duodenal switch with biliopancreatic diversion later, typically over a year if further weight loss is needed.

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11
Q

What prophylactic measures should be taken on the morning of bariatric surgery?

A

Administration of appropriate antibiotics and subcutaneous unfractionated or low-molecular-weight heparin

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12
Q

How far distal to the ligament of Treitz is the jejunum typically transected during a Roux-en-Y gastric bypass?

A

Approximately 40 to 75 cm distal to the ligament of Treitz.

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13
Q

What stapler cartridge is used to transect the jejunum in Roux-en-Y gastric bypass?

A

A 60-mm white stapler cartridge.

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14
Q

How far distal from the point of division is the biliopancreatic limb anastomosed to the distal jejunum segment?

A

75 to 100 cm distal from the point of division.

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15
Q

What orientation is the Roux limb brought up to the gastric pouch in, and why?

A

Antecolic-antegastric orientation, as it reduces internal hernias, provides excellent exposure, and is simpler than a retrocolic-retrogastric approach.

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16
Q

Which stapler cartridge is used to create the gastrojejunostomy?

A

A 60-mm blue cartridge, using only the first 40 mm of the staple cartridge

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17
Q

What size bougie is used to assist in creating the proximal gastric pouch and as a guide along the lesser curve?

A

A 40 French bougie.

18
Q

What diameter is the completed gastrojejunostomy anastomosis?

A

Approximately 12 mm in diameter.

19
Q

How is a leak test performed on the gastrojejunostomy?

A

By clamping the Roux limb distal to the anastomosis and insufflating air via an endoscope or orogastric tube while submerging the gastric pouch in saline

20
Q

What is closed after the anastomosis to prevent internal hernias?

A

The mesenteric defect between the Roux limb mesentery and the transverse mesocolon, up to the transverse colon.

21
Q

What is the primary mechanism of weight loss in laparoscopic vertical sleeve gastrectomy (LVSG)?

A

Restriction, by removing the lateral aspect of the stomach to create a sleevelike tube or reservoir

22
Q

How does LVSG contribute to hormonally assisted satiety?

A

By removing the fundus, which produces the proappetite hormone ghrelin, leading to reduced ghrelin levels post-surgery.

23
Q

When might an LVSG need to be revised to a Roux-en-Y gastric bypass?

A

If postoperative complications such as gastric stricture or severe gastroesophageal reflux disease (GERD) occur.

24
Q

Why is it important to avoid stapling too close to the incisura angularis during LVSG?

A

Stapling too close may lead to a gastric stricture.

25
Q

What type of bariatric surgery is the laparoscopic duodenal switch with biliopancreatic diversion (DS-BPD)?

A

Primarily a malabsorptive procedure
Involves pylorus preservation and creation of a short, 100-cm ileal “common channel”

26
Q

Why is the DS-BPD less commonly performed compared to other bariatric procedures?

A

Higher surgical complexity
Potential for severe malabsorptive nutritional deficiencies
Risk of diarrhea

27
Q

In which situations is DS-BPD performed in two stages?

A

For patients with high BMI (> 70)
First stage involves a vertical sleeve gastrectomy (VSG)
Second stage (malabsorptive part) typically done 1-2 years later

28
Q

Describe the steps of the second stage in a two-stage DS-BPD.

A

Divide the small bowel 250 cm from the ileocecal valve.
Anastomose the proximal end to the distal ileum 100 cm from the cecum

29
Q

At what point is the duodenum divided, and with what instrument?

A

Duodenum divided approximately 3 cm distal to the pylorus
Blue Endo GIA 60-mm stapler is used

30
Q

What are the alternative names for the laparoscopic single anastomosis duodenal switch (SADI-S)?

A

Loop duodenal switch
Single-anastomosis duodenoileal bypass with sleeve gastrectomy

31
Q

what is its benefit compared to DS-BPD?

A

Easier to perform and possibly a lower rate of internal herniation than DS-BPD

32
Q

How does SADI-S differ from DS-BPD in terms of biliopancreatic diversion?

A

SADI-S does not divert biliopancreatic fluid because it lacks a Roux limb.
Has a loop anastomosis that could make leaks more challenging to manage.

33
Q

What is the controversy regarding the size of the bougie and the length of the absorptive limb in SADI-S?

A

Bougie size reduced to 40 French by many surgeons.
Absorptive limb length increased from 200 to 300 cm to reduce protein and vitamin deficiencies.

34
Q

What is a potential benefit of increasing the length of the absorptive channel in SADI-S?

A

Reduces the risk of diarrhea while still supporting effective weight loss.

35
Q

What are the primary early (perioperative) complications of bariatric surgery?

A

Bleeding
Anastomotic leakage
Deep venous thrombosis (DVT)

36
Q

What might persistent tachycardia (HR > 120 bpm) indicate early after bariatric surgery?

A

Possible early sign of sepsis
Should prompt an appropriate workup

37
Q

Which vitamin and nutrient deficiencies are commonly seen as long-term complications of bariatric surgery?

A

Vitamin B12
Calcium
Iron
Vitamin D
Protein

38
Q

What symptoms are associated with Vitamin B1 (thiamine) deficiency in post-bariatric surgery patients?

A

Paresthesias in extremities
Confusion
Nystagmus

39
Q

What are symptoms of Vitamin B12 deficiency in post-bariatric surgery patients?

A

Lower extremity weakness
Paresthesias

40
Q

What percentage of patients experience anastomotic stenosis or obstruction after gastric bypass, and how is it usually treated?

A

Occurs in less than 5% of patients
Managed with endoscopic dilation

41
Q

What are the symptoms of an internal hernia after bariatric surgery?

A

Acute bowel obstruction symptoms
Chronic postprandial periumbilical cramping pain

A1-G Surg Note Stomach (11 decks)

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