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Clin Med - II (Surgery) > Obesity > Flashcards

Obesity Flashcards

1
Q

Obesity - E/E

A

One of the most common d/o in medicine
According to WHO 500 million adults worldwide, 42 million children
Increased healthcare costs
Can be one of the most frustrating d/o to manage
Advances have been made with time
Continues to increase nationwide
Obesity stigma
Women > Men
68% of Americans are overweight based on BMI
Socioeconomic factors play a significant role
Ethnicity can have a major influence
Gentic predisposition
Medical condition
MULTIFACTORIAL!

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2
Q

Genetics and obesity

A

Five gene identified
All affect control of appetite from a neuroendocrine standpoint
- Leptin
- Grehlin

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3
Q

Economical Impacts of Obesity - Personal Level

A 
$1,000's
Additional medication cost
Out-of-pocket healthcare expenses
Costs related to inactivity
Commercial weight loss program fees
Additional food costs
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4
Q

Economical Impacts of Obesity - National level

A

Billions yearly

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5
Q

Economical Impacts of Obesity - Business level

A

More than $12 billion for employee care

5% of total healthcare expenditures

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6
Q

Assessing obesity

A

EVERYONE!!
Record and trend BMI
Assess for co-morbid dz in anyone with a BMI of 25 or greater

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7
Q

Obesity related Co-morbidities

A 
DM-2
HTN
OSA
Dyslipidemia
OA
GERD
Ca
Back/joint pain
Urinary stress incontinence
Asthma
OHS
CAD / CHD
NASH / NAFLD
Pseudotumor cerebri
Infertility - PCOS
Psychological - Depression / Anxiety
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8
Q

BMI of normal weight

A

18.5 - 24.9

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9
Q

BMI of overweight

A

25 - 29.9

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10
Q

BMI of Obese (Class I)

A

30 - 34.9

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11
Q

BMI of Obese (Class II)

A

35-39.9

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12
Q

BMI of extremely obese (Class III)

A

40+

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13
Q

BMI

A

A measurement based on weight and height

Used to help determine the degree or severity of a person’s obesity

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14
Q

Medical evaluation

A 
Age of onset
Weight changes
FHx
Social hx
Occupational hx
Eating habits
Exercise habits
Previous effeorts to address
Assess for eating d/o
- Laxative use
- Diuretic use
- Nutritional supplements
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15
Q

Secondary Obesity

A 
<1% have an attributable cause
Hypothyroidism
Cushing's dz or syndrome
Other genetic conditions
- Prader-Willi Syndrome
- Alstrom Syndrome
- Cohen Syndrome
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16
Q

Weight loss strategies - in general

A 
Dietary intervention
Physical activity
Behavior modification
Drug tx
Weight loss sx in the severely obese
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17
Q

Weight loss strategies - Dietary intervention

A

About 10% of body weight and be healthfully lost in 6 months

Diets are prone to failure for many reasons

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18
Q

Weight loss strategies - Physical activity

A

Increased activity can improve general health, but may have little impact on total body weight in morbid obesity

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19
Q

Weight loss strategies - behavior modification

A

Can contribut to overall weight loss program
Requires ongoing professional contact
Failure rate can be high

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20
Q

Weight loss strategies - Drug tx

A

Weight is typically regained when tx ends

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21
Q

Weight loss strategies - sx

A

Weight loss sx in the severely obese

The most effective approach for long-term weight loss

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22
Q

Dietary intervention - in general

A

Changing dietary habits
Daily Caloric intake
Long term success of dieting alone is poor
The higher the weight loss the harder it is to keep it off

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23
Q

Dietary intervention - Changing Dietary Habits

A

Diets

Calorie counting

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24
Q

Dietary intervention - Daily caloric intake

A 
Requirements depend on numerous factors
- Age
- Sex
- Physical activity
- Health conditions
Males: 2000-3000 /day
Females: 1600-2400/day
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25
Q

Dietary intervention - Long term success

A

Only 20% will lose 20 lbs and keep it off for 2 years

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26
Q

Physical Activity

A

Calorie expenditure > intake
Typically a combination is best
5-7 days/week
Moderate Activity (100-130HR)

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27
Q

What is the best way to optimize fatty weight loss

A

A combination of diet and exercise

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28
Q

Behavior Modification

A

Esp. if weight gain is related to psychological eating d/o
Maintenance
Social support system!

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29
Q

Medications - in general

A

OTC & prescriptions
Routine f/u
Do they work?

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30
Q

Medications - NIH/FDA recommendations

A

Part of comprehensive program
BMI > 30
BMI > 27 if they have a medical co-morbidity

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31
Q

Medications - Examples

A 
Xenical (Orlistat)
Belviq (Lorcaserin)
Phentermine
Topriamate
Saxenda (Liraglutide)
Qsymia
Contrave
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32
Q

Xenical (Orlistat)

A 
Long term tx
TID with meals
MOA - GI tract
SE - GI
Risks - Malabsorption
2-4 kg > placebo
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33
Q

Belviq (Lorcaserin)

A 
Shorter term tx
MOA - SSRA
Risks
- NMS
- Serotonin syndrome
- Breast tumors?
- Valvular HD?
3% > weight loss than placebo
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34
Q

Phentermine

A 
Short term
Strict f/u is required
Two doses
- 15 mg
-37.5 mg
- QD 1-2h after breakfast
SE/risk
- Insomnia
- Fatigue
- CV
Better results
-7.8% &amp; 9.8% > placebo
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35
Q

Topiramate

A

Anticonvulsant
Off label use for weight loss
Typical dose - 25mg BID
Black box warning - birth defects

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36
Q

Saxenda (liraglutide)

A 
Injectable
Incretin (GLP-1 agonist)
FDA approved for weight loss
Dosage - 3 mg
SE - GI; Pancreatitis
Black box warning - carcinogen?
3.7-4.5% > loss than placebo at 1 year
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37
Q

Combination drugs

A

Qsymia

Contrave

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38
Q

Qsymia

A 
Phentermine / Topirmate
Dosage: 7.5/46mg; 15/92 mg
Contraindication: Hyperthyroidism; Glaucoma
SE
- Dizziness
- Paresthesias
- CV
- Psychologial
- GI
Black box warning - Birth defects
6.7% &amp; 8.9% weight loss at 1 year
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39
Q

Contrave

A 
Bupropion / Naltrexone
Dosage
- 8/90 mg
- Complicated dosing to start medication
- EDUCATE!
Risk / SE
- CV outcome in trial progress (HTN; tachycardia)
- GI
- Neuropsychiatric
2-4% > Placebo
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40
Q

Expectations of weight loss tx

A 
Placebo
- 4-6% weight loss
- 0% (5 years)
Diet/behavior modification
- 8-12% weight loss
- 1.6% (10 years)
Drug therapy
- <10% weight loss
- 10% (5 years)
Gastric bypass sx
- 65-85% weight loss
- Up to 100% (5 years)
Lap. vert. sleeve gastrectomy
- 59% weight loss
- Up to 100% (5 years)
41
Q

Bariatric surgery - in general

A

An option for individuals who have failed more conservative measures
The single most effective means of long terms weight loss
M/M risks in sx < non-sx obese pts with chronic dz
US and Canada > 100,000 / year

42
Q

Bariatric surgery - Criteria

A 
BMI > 40 w/o co-morbidity
BMI > 35 with obesity related co-morbidities
Must not have contraindications to sx
BMI 30-34.9 - metabolic
- Uncontrollable DM-2
- Metabolic syndrome
43
Q

Bariatric surgery - Contraindications

A 
No absolute contraindications
Anorexia nervosa or bulimia nervosa
Scleroderma (consider lap band)
Surgeon must exercise good judgment in selection
- Cirrhosis
- Previous sx
- Large ventral hernias
- large hiatal hernias
 - various medical conditions (cardiomyopathy, stroke, sever coagulopathy)
- psychiatric illness
- OBD
- Connective tissue d/o
- Noncompliance
44
Q

Bariatric surgery - Choosing a surgeon

A

Research
Resources
Organized program / multidisciplinary program - support groups
Center of Excellence (ASMBS)

45
Q

Center of excellence

A

Training requirements
Procedure requirements - surgeon and facility
Hospital requirements - infrastructure
Program requirements - multidisciplinary

46
Q

Bariatric surgery - Preparing the patient for surgical referal

A

Referral
Enroll in a multidisciplinary program
Pt seminar

47
Q

Bariatric surgery - Pre-op requirements

A 
Documented medically supervised wt loss w/o sig. reduction
Optimized co-morbidities
Behavior medicine
Dietary and exercise physiology eval
Meet with surgeon a minimum of two times
Assure pt's understanding f o post-op expectations
Pre-op testing
Pre-op low calorie diet
48
Q

Bariatric surgery - Procedures in general

A

Restrictive

Combination

49
Q

Bariatric surgery - Restrictive procedures

A

Sleeve gastrectomy (LVSG)
Adjustable gastric banding (AGB
Vertical banded gastroplasty (VBG)

50
Q

Bariatric surgery - Combination procedures

A 
Roux-en-Y gastric bypass
Biliopancratic diversion (BPD)
Duodenal switch (DS)
51
Q

Adjustable gastric banding - Advantages

A 
AGB
Not permanent
Less short term complications
Quick recovery
Same anatomy
20-50% EBWL
Lowest mortality and complication rates
52
Q

Adjustable gastric banding - Disadvantages

A 
Foreign body
Frequent f/u
60% re-operation rate
Long-term complications high
Many require removal
53
Q

Adjustable gastric banding - Complications

A 
Dysphagia
N/V
Pain (epigastric &amp; port site)
GERD
Aspiration
Band leak
Band slippage
Band erosion
Port leak
Flipped port
Esophageal dilation
54
Q

Roux-en-Y Gastric Bypass - In General

A 
RNYGB
Overall very good weight loss
Combo procedure - restrictive and malabsorptive
Higher risk but better return
Instant improvement in DM/hyperglycemia
Less frequent f/u than AGB
Must monitor long-term for deficiencies
- Risk for hypovitaminosis
- Dependent upon length of limbs
55
Q

Roux-en-Y Gastric Bypass - Advantages

A 
Rapid initial weight loss
Less frequent f/u required
No implant
Laparoscopic approach
Longer track record in US
56
Q

Roux-en-Y Gastric Bypass - Disadvantages

A 
Stomach cutting, stapling and intestinal rerouting requires
Risk for hypovitaminosis
Higher short term complications and mortality rates than LAP-BAND
Potential for nutritional deficiencies
"Dumping  syndrome" can occur
Not adjustable
Difficult to reverse
Longer hospital stay and recovery
57
Q

Dumping syndrome

A

Massive insulin release b/c of something the pt ate

58
Q

Roux-en-Y Gastric Bypass - Complications (early)

A 
Pneumonia - 0.14%
Oxygen insufficiency - 0.48%
Leaks - 2.05%
Wound infection - 2.98%
GI Bleeding / hemorrhage - 1.93%
PE - 0.41%
Bowel obstruction - 1.73%
Death - 0.23%
N / V
59
Q

Roux-en-Y Gastric Bypass - Complications (late)

A 
Strictures - 4.73%
Incisional hernia (laproscopic) - 0.47%
Incisional Hernia (Open sx) - 8.58%
SBO - 3.15%
Anemia &amp; B12 deficiency
Ulcers / gastritis
Cholelithiasis
Internal hernia  / intestinal ischemia
60
Q

Roux-en-Y Gastric Bypass - complications (leaks)

A

Rare, but can occur at any 5 internal staple line
pH of gastric content is very irritating to lining of abdomen and internal organs
Can quickly lead to sever infection, septic shock
Death may result
Re-operation required to find and repair the leak
Early detection and tx is key!!!

61
Q

Most common leak site of the Roux-en-Y Gastric Bypass

A

Pouch to intestine

62
Q

Roux-en-Y Gastric Bypass - Outcome

A 
60-70% EBWL
>75% control of co-morbidities
- DM-2 83.8% resolution
- HTN 75.4% resolution
- OSA 86.6 resolution
63
Q

Roux-en-Y Gastric Bypass - Supplementation

A

Adult multivitamin
Vit. B12
Calcium (citrate) plus Vit, D
Iron on occasion

64
Q

Laproscopic Vertical Sleeve Gastrectomy - In general

A 
LVSG
Descendant of the BPD and DS
Initially used as a staged procedure
Restrictive only - endocrine influence
Maintain continuity
Risk < RNYGB
Risk > AGB
Still recommend supplementation however for low risk for hypovitaminosis
65
Q

Laproscopic Vertical Sleeve Gastrectomy - Grehlin influence

A

Member of Motilin family of gut peptide hormones
Ligand for growth hormone secretigogue receptor
90% secreted in stomach and duodenum P/D1 cells

66
Q

Function of Grehlin

A

Increase GH secretion
Increase food intake
Weight gain

67
Q

Laproscopic Vertical Sleeve Gastrectomy - Advantages

A 
Laparoscopic
May be an option for carefully selected pts, including high-risk or super-super-obese pts
Mean excess weight loss at 1yr of 59%
No implanted medical device
Less frequent f/u required
Maintain continuity
68
Q

Laproscopic Vertical Sleeve Gastrectomy - Disadvantages

A

Stomach cutting adn stapling required
Not reversible
Inpatient hospital stay and somewhat longer recovery than gastric band
Insurance

69
Q

Laproscopic Vertical Sleeve Gastrectomy - Complications (early)

A 
Hemorrhage (0.7-1.8%)
Leaks (0.7-0.8%
Death (0.39%)
Wound infection
PE
Pneumonia
Oxygen insufficiency
Stenosis
70
Q

vLaproscopic Vertical Sleeve Gastrectomy - Complications (late)

A 
Structure
Acid reflux
Incisional hernia
SBO
Ulcers / gastritis
Cholelithiasis
71
Q

Laproscopic Vertical Sleeve Gastrectomy - Outcomes

A

Good weight loss and long term results
55-65% EBWL
Resolution of co-morbidities come with weight changes
Slower results but still excellent resolution potential

72
Q

Biliopancreatic Diversion with Duodenal Switch - in general

A

BPD-DS
Initially started as BPD alone
Pt selection is key
Close f/u is a must

73
Q

Biliopancreatic Diversion with Duodenal Switch - modifications

A

DS
Sleeve
Laparoscopic approach

74
Q

Biliopancreatic Diversion with Duodenal Switch - Advantages

A

Very rapid inital weight loss
Weight loss continues beyond 12m at a slower rate
No foreign body
Very good resolution of co-morbidities
Best EBWL of any wt loss procedure
Now laparoscopic and robotic approaches available
Good option for wt loss in super morbidly obese (esp. BMI>60)

75
Q

Biliopancreatic Diversion with Duodenal Switch - Disadvantages

A 
Non-reversible
Staling/cutting of viscera
Hypovitaminosis
Close f/u requires
Longer hospital stay
Long term nutritional monitoring a must
76
Q

Biliopancreatic Diversion with Duodenal Switch - Complications (early)

A 
Higher mortality - 30d rate 2.6-7.6%
Anastomotic leak
Duodenal stump leak
Intra-abdominal abscess
Hemorrhage
VTE
Bowel obstruction
N/V
77
Q

Biliopancreatic Diversion with Duodenal Switch - Late

A 
Bowel obstruction
Internal hernia
Structure (2 locations)
Nutritional deficiency
- Iron
- Calcium / Vit. D
- B12
- Folate
- Fat soluble vitamins in certain situations
Diarrhea
Cholelithiasis
78
Q

Biliopancreatic Diversion with Duodenal Switch - Outcomes

A 
EBWL 70-80%
DM-2 - 90% resolution at 12-36m
HTN - 50-80% resolution
OSA - 98% resolution
Dyslipidemia improvment / resolution
Better outcomes than any other procedure
79
Q

Vertical Banded Gastroplasty - In General

A

VBG
Not routinely performed any longer
Still a sig. amount of pts around

80
Q

Vertical Banded Gastroplasty - common complications

A

Staple line breakdown (gastrogastric fistula)
Gastric outlet obstruction
Incisional hernia

81
Q

Other weight loss surgeries - Types

A

Vagal N. stimulators
Gastric plication
Band over
Endoscopic gastric balloon

82
Q

Complications - N/V

In general

A

Often the most common complaint after sx
Typically acute post-op but can become chronic
Places at risk for dehydration post-op

83
Q

Complications - N/V

Tx

A 
First line
- Zofran
- Reglan
- Phenergan
- Compazine
Second line
- Decadron
- Levsin
- Marinol
84
Q

Complications - Reflux

In general

A

More common in LVSG

Signifies underlying pathology in RNY/BPD but can be a sign of pathology with LVSG

85
Q

Complications - Reflux Associated complications

A

Ulcer
Stricture
Gastrogastric fistula

86
Q

Complications - Reflux

Work-up

A

UGI
EGD
24h pH - in select cases

87
Q

Complications - Reflex

Tx

A

PPI +/- Carafate

Sx to correct complication or to alleviate

88
Q

Complications - Anastomotic ulcer

In General

A

Common late complication of RNYGB, BPD

Located at the gastrojejunostomy

89
Q

Complications - Anastomotic ulcer

Dx and Tx

A

DX - EGD

TX

  • Educate
  • Referral back to bariatric surgeon
  • PPI
  • Carafate
  • Sx
90
Q

Complications - Strictures

In General

A

Can be seen in RNYGB, LVSG, BPD-DS
Often associated with smoking
RNY - gastrojejunostomy, jejunojejunostomy
LVSG - Insisura, GE junction (Angle of His)
BPD/DS - Duodenojejunostomy

91
Q

Complications - Strictures

Tx

A

STOP SMOKING!!!
PPI
EGD with dilation
Sx

92
Q

Complications - internal hernia

A

Can arise at any of the multiple mesenteric defects associated with any malabsorptive procedure
Must be a consideration in these pt with chronic post-prandial abdominal pain
Place pt at risk for an acute ischemic event involving affect segments

93
Q

Complications - internal hernia

Work-up and Tx

A

Work-up

  • Work-up may be negative
  • UGI / Small Bowel series
  • EGD
  • CT abdomen and pelvis with contrast
  • Diagnostic laparoscopy

Tx - sx (open vs. laparoscopic)

94
Q

Complications - Post-op

In general

A

Long term success is dependent on f/u
Monitor for short and long term complications
Monitor dietary habits, exercise habits, aid in accountability
Should see surgeon frequently in 1st year

95
Q

How often should post-op f/u for bariatric sx occur?

A

1 week
1 month
Quarterly
F/u yearly thereafter

Routine dietary, exercise and psychology f/u is a must

96
Q

Complications - Hypovitaminosis

A

Can be due to procedure
Can have influence from complications post procedure
Long term actid suppression meds can influence
Key players - B12, Magnesium, Calcium

97
Q

Supplementation - ASMBS Guidlines

A 
Lifelong supplementation for all bariatric sx pts
Adult multivitamin
- Vit B12
- Iron
- Vit A
- Vit D3
- Folic Acid
- Thiamine (B1)
- Zinc
- Copper
- Vit C
- Biotin (optional)
Calcium / Vit. D
Vit. B12 - RNYGB, BDP-DS, Sleeve?
98
Q

PCP role - Pre-op

A

Assess all individuals at risk
Optimize medical conditions related to obesity
Medially managed weight loss regimen
Referral for behavior modification
Medications
Initiate referral process for bariatric sx
DOCUMENT

99
Q

PCP role - Post-op

A

Good communication with specialists - labs
Early and frequent f/u initially
Routine f/u long term
Co-morbidities
Be able to identify early and lat complications
Long-term nutritional mainentance
Refer back to bariatric surgeon with complications
If symptoms arise think common things but never forget to assess their post sx anatomy

Clin Med - II (Surgery) (10 decks)

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