Morbid Obesity Flashcards
What BMI qualifies a patient for bariatric surgery, regardless of comorbidities?
A BMI of 40 kg/m² or greater
What BMI range qualifies a patient for bariatric surgery if obesity-related comorbidities are present?
A BMI between 35 and 40 kg/m², with conditions such as diabetes or hypertension.
According to the ASMBS, when should bariatric surgery be considered for patients with class I obesity (BMI 30–35 kg/m²) and comorbidities?
After failure of nonsurgical treatment methods, and it should be strongly considered for patients with type 2 diabetes
What alternative treatments may be considered for patients with a BMI of 30 to 40 kg/m² who cannot undergo bariatric surgery?
Intragastric balloon (IGB) or endoscopic sleeve gastroplasty (ESG).
Why might a patient choose IGB or ESG over bariatric surgery?
Due to contraindications for surgery (e.g., hostile abdomen, large ventral hernia) or unwillingness to undergo surgery despite understanding its effectiveness
What should candidates for bariatric surgery demonstrate before surgery is considered?
Prior attempts at nonsurgical weight loss options, including dietary interventions, pharmacologic therapy, or behavioral modifications.
relative contraindications for bariatric surgery?
Inability to comply with postoperative requirements, active alcohol or substance abuse, and uncontrolled psychiatric disease
What is the recommended approach to evaluating candidates for bariatric surgery
A multidisciplinary team approach
Which professionals should be included in the bariatric surgery evaluation team?
A dietician and a mental health professional with experience in bariatric surgery
What is a staged operation in bariatric surgery?
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.
What prophylactic measures should be taken on the morning of bariatric surgery?
Administration of appropriate antibiotics and subcutaneous unfractionated or low-molecular-weight heparin
How far distal to the ligament of Treitz is the jejunum typically transected during a Roux-en-Y gastric bypass?
Approximately 40 to 75 cm distal to the ligament of Treitz.
What stapler cartridge is used to transect the jejunum in Roux-en-Y gastric bypass?
A 60-mm white stapler cartridge.
How far distal from the point of division is the biliopancreatic limb anastomosed to the distal jejunum segment?
75 to 100 cm distal from the point of division.
What orientation is the Roux limb brought up to the gastric pouch in, and why?
Antecolic-antegastric orientation, as it reduces internal hernias, provides excellent exposure, and is simpler than a retrocolic-retrogastric approach.
Which stapler cartridge is used to create the gastrojejunostomy?
A 60-mm blue cartridge, using only the first 40 mm of the staple cartridge
What size bougie is used to assist in creating the proximal gastric pouch and as a guide along the lesser curve?
A 40 French bougie.
What diameter is the completed gastrojejunostomy anastomosis?
Approximately 12 mm in diameter.
How is a leak test performed on the gastrojejunostomy?
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
What is closed after the anastomosis to prevent internal hernias?
The mesenteric defect between the Roux limb mesentery and the transverse mesocolon, up to the transverse colon.
What is the primary mechanism of weight loss in laparoscopic vertical sleeve gastrectomy (LVSG)?
Restriction, by removing the lateral aspect of the stomach to create a sleevelike tube or reservoir
How does LVSG contribute to hormonally assisted satiety?
By removing the fundus, which produces the proappetite hormone ghrelin, leading to reduced ghrelin levels post-surgery.
When might an LVSG need to be revised to a Roux-en-Y gastric bypass?
If postoperative complications such as gastric stricture or severe gastroesophageal reflux disease (GERD) occur.
Why is it important to avoid stapling too close to the incisura angularis during LVSG?
Stapling too close may lead to a gastric stricture.
What type of bariatric surgery is the laparoscopic duodenal switch with biliopancreatic diversion (DS-BPD)?
Primarily a malabsorptive procedure
Involves pylorus preservation and creation of a short, 100-cm ileal “common channel”
Why is the DS-BPD less commonly performed compared to other bariatric procedures?
Higher surgical complexity
Potential for severe malabsorptive nutritional deficiencies
Risk of diarrhea
In which situations is DS-BPD performed in two stages?
For patients with high BMI (> 70)
First stage involves a vertical sleeve gastrectomy (VSG)
Second stage (malabsorptive part) typically done 1-2 years later
Describe the steps of the second stage in a two-stage DS-BPD.
Divide the small bowel 250 cm from the ileocecal valve.
Anastomose the proximal end to the distal ileum 100 cm from the cecum
At what point is the duodenum divided, and with what instrument?
Duodenum divided approximately 3 cm distal to the pylorus
Blue Endo GIA 60-mm stapler is used
What are the alternative names for the laparoscopic single anastomosis duodenal switch (SADI-S)?
Loop duodenal switch
Single-anastomosis duodenoileal bypass with sleeve gastrectomy
what is its benefit compared to DS-BPD?
Easier to perform and possibly a lower rate of internal herniation than DS-BPD
How does SADI-S differ from DS-BPD in terms of biliopancreatic diversion?
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.
What is the controversy regarding the size of the bougie and the length of the absorptive limb in SADI-S?
Bougie size reduced to 40 French by many surgeons.
Absorptive limb length increased from 200 to 300 cm to reduce protein and vitamin deficiencies.
What is a potential benefit of increasing the length of the absorptive channel in SADI-S?
Reduces the risk of diarrhea while still supporting effective weight loss.
What are the primary early (perioperative) complications of bariatric surgery?
Bleeding
Anastomotic leakage
Deep venous thrombosis (DVT)
What might persistent tachycardia (HR > 120 bpm) indicate early after bariatric surgery?
Possible early sign of sepsis
Should prompt an appropriate workup
Which vitamin and nutrient deficiencies are commonly seen as long-term complications of bariatric surgery?
Vitamin B12
Calcium
Iron
Vitamin D
Protein
What symptoms are associated with Vitamin B1 (thiamine) deficiency in post-bariatric surgery patients?
Paresthesias in extremities
Confusion
Nystagmus
What are symptoms of Vitamin B12 deficiency in post-bariatric surgery patients?
Lower extremity weakness
Paresthesias
What percentage of patients experience anastomotic stenosis or obstruction after gastric bypass, and how is it usually treated?
Occurs in less than 5% of patients
Managed with endoscopic dilation
What are the symptoms of an internal hernia after bariatric surgery?
Acute bowel obstruction symptoms
Chronic postprandial periumbilical cramping pain
