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Bariatric surgery > Risks > Flashcards

Risks Flashcards

1
Q

Target EBWL of lap.gastric banding

TBW?

A

35-40% EWL
TBW 20-25

> 40% regain their weight

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2
Q

Target EBWL of Sleeve gastrectomy

A

55-70%

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3
Q

Target EBWL of RYGB

A

60-75% EXCESS body weight.
Better if BMI<50
long term 20% regain most of their weight

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4
Q

Target EBWL of BPD/DS

A

70-80%

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5
Q

Gastric band cons 4

A

Erosion,
slip/prolapse,
explant (removal) rate 40%,
failure to lose 25% excess body weight |

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6
Q

Sleeve gastrectomy complications 3

A

20-30% NEW GERD
Leaks
stricture/ stenosis

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7
Q

unfavorable aspects of RYGB 5

A 
Few revision options
Marginal ulcers 20%
Internal hernias
Long term micronutrient deficiencies
Anemia
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8
Q

Favorable aspects biliopancreatic diversion with duodenal switch 4

A

very strong metabolic effects
Durable weight loss
Effective for patients with very high BMI
Can be used as second stage after sleeve gastrectomy

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9
Q

Cons of duodenal switch 4

A
  • Malabsorptive/-highest rate micronutrient deficiencies
  • GERD
  • 3-5% protein-calorie malnutrition
  • duodenal dissection
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10
Q

ASMBS impact of min 5% weight loss

A

T2D
dyslipidemia, HTN,
NAFLD

low testosterone, PCOS

( AOS/reactive airways) 7-8%

urinary stress incontinence,

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11
Q

ASMBS impact of min 10% weight loss 6

3 metabolic, 2 fat mass, 1 psych

A

MetS,
prediabetes,
NASH,

OA,
GERD,

depression

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12
Q

Relative CIs for bariatric surgery

A
  1. Hx substance abuse/eating disorder, smoking
  2. Hx psychiatric hospitalization in last year, suicidal ideation, major psych issue
  3. Patients too ill or high risk
  4. Women wanting to conceive within 12 mos.
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13
Q

Who has increased risk for weight loss surgery?

mostly common sense

A

Old fat smoking diabetic men (BMI>50,age>60)
Cardiac Hx:HTN, CAD with prior MI/PTCA, unstable angina, CHF
Pulmonary hx:COPD,OSA,pulmHTN low baseline O2
Hx/Fhx thromboembolic disease
End organ failure/transplant, non-ambulatory, ECOG<2

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14
Q

Pre-op weight loss benefit 3

A

Decreased OR time
Smaller liver size
reduced peri-operative complications

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15
Q

Gastric bypass OR time/hospital stay/recovery

Gastric sleeve OR/hospital stay/recovery

A

1hr40min/1-3 days/4-6 weeks

1 hr/ 1-2 days/2-3 weeks

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16
Q

Lap adjustable Gastric Banding - approved for what BMI

A

BMI 30-35

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17
Q

Sleeve gastrectomy- how much of stomach removed, what is volume remaining, how does it work??

A

75-80% removed,
60-100 ml left
Removes greater curve, greatly reducing Ghrelin production

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18
Q

What is involved in a Biliopancreatic diversion with a Duodenal switch?
( BPD-DS)

A

sleeve gastrectomy+>80%small bowel bypassed, absorptive channel reduced to 75-150 cm

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19
Q

What is a Loop duodenal switch ( SADIS or SIPS)

A

sleeve gastrectomy and about 50% bypassed small bowel, absorptive channel remaining 300 cm

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20
Q

EWL for BPD-DS at 10 years

A

70-80%

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21
Q

EWL with loop duodenal switch

* EBW is the amount of body weight you have in excess of your target weight

A

70-80%

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22
Q

Which non-obesity and obesity related medical conditions is sleeve gastrectomy best for 4

A

Kidney stones
Hx or pending organ transplant
Higher pre=op cardio-pulmonary risk
Severe baseline nutritional deficiencies

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23
Q

Which procedure is best if patient has GERD?

A

RNY

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24
Q

best procedures if BMI>50 or Type II DM

A

RNY or BPD , SIPS**

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25
Q

How does post-op rhabdomyolysis present? 2 labs 2 symptoms

A

low urine output, dark urine, elevated CPK and myoglobin in urine

26
Q

How do leaks present post-op? When, where, how? What tests to order? detailed slide

A
  1. Early, in first 2 weeks
  2. at GJ anastamosis or proximal staple line
  3. tachycardia,worsening abd/left chest pain, leukocytosis,fever,oliguria, LEFT PLEURAL EFFUSION
  4. Tests - UGI study, CT, amylase
27
Q

About post-op bleeding - where, treatment/investigation

A

Luminal (hematesis,BRBPR) or intraperitoneal ( bloody drain output)
Resuscitate, hold anti-coag, correct coags and transfurse PRN
EGD PRN if intraluminal bleeding
Usually settle without intervention

28
Q

Marginal ulcers after RNY 1-7(20%). What triggers them 6 how to treat?

A 
NSAIDS
caffeine
ETOH
Diabetes
Smoking
systemic steroids
treat- Sucralfate, PPI, improve nutrition, stop smoking
29
Q

Post-op DVT/PE - how common, presentation, investigation

A

1% fatal PE
tachycardia, O2 desat., SOB, chest pain
do CT angio

30
Q

Anastomotic stricture/stenosis - up to 27% after GBP

Symptoms 3? Treatment?

A
  1. dysphagia, solid food intolerance, excessive OR poor weight loss
  2. Treatment - balloon dilatation
31
Q

Internal hernias occur late, 1-2 years post-op. How to diagnose?

A

Abdominal pain, N/V, non-specific symptoms.
Order KUB/CT scan - “swirl sign”
up to 50% need surgical exploration

32
Q

Lap. gastric banding “erosion” symptoms 3

A

No symptoms
“Loss of restriction”
Pain/inflammation or infection at port site

33
Q

Post-op vitamins 5

A 
MVI: 2 daily with 18-27 mg IRON
Calcium citrate 1200-1500  mg
vitamin D 3000 IU (goal >30)
vitamin  B12 300-500 mcg po/SL QD/
1000 mcg SC qmonth
 500-1000 mcg intranasal weekly

(Folate 400-1000 mcg QD
CU 1-2 mg/day

check Cu,Zn,Se

34
Q

Insufficient weight loss = losing less than 40-50 % EBW. Post- surgical reasons 3?

A

Large or dilated gastric pouch
Dilated G-J anastomosis
Gastro-gastric fistulas

35
Q

Excessive weight loss/Protein malnutrition.

Differential Dx:4 surgical complications + 1 psych

A 
Anorexia nervosa or bulemia
Surgical:
Vomitting due to Anastomotic stenosis 
Vomitting due to ulcers 
Intestinal bacterial overgrowth
Too much intestine bypassed.
36
Q

Biliary complications - gall stone formation more common with bypass surgery. Rate of cholecystectomy required, preventative treatment

A

8% need surgery, even though 36% develop stones

Can give ursodeoxycholic acid for 6 months but compliance can be poor

37
Q

Refeeding syndrome presentation - 3 lab and 4 symptoms

A

Hypo Mag, K , PO4

Cardiac arrythmias, weakness, seizures, coma

38
Q

Dumping syndrome=rapid emptying of hypertonic carb load into small bowel. <1hour - Distention of small bowel Late 1-3 hours-Causes rapid glucose absorption, hyperglycemia, exaggerated insulin release and hypoglycemia.
Symptoms

A

Abdominal pain, cramping, flushing, palpitations, diaphoresis, tachycardia, hypotension, tremors, confusion, seizures

39
Q

Most common deficiency after GBP, and why 3

A 
Iron deficiency anemia
1.decreased acid secretion in gastric pouch
2. Chronic use of H2 blockers and PPIs
3. Decreased intake of iron rich foods
Monitor 2x/year
40
Q

Vitamin B12 deficiency 26-70% - reasons 3 and symptoms/abnormalities 5

A
  1. Achlorhydria
  2. Decreased consumption
  3. Less intrinsic factor secretion
    Neurologic symptoms,
    megaloblastic anemia ( also found in COPPER deficiency), low platelets, low WBC,
    glossitis
41
Q

Folic acid deficiency - causes,supplementation dose

A

Achlorhydria
Associated with Vit B12 deficiency and decreased consumption.
1 mg/day

42
Q

Thiamine deficiency after bariatric surgery causes 3
symptoms 5
dose

A

Increased loss - excessive post-op vomitting
Reduced absorption -due to decreased acid and duodenal exclusion in gastric bypass.
Sx: lower extremity weakness/neuropathy/nystagmus/diploplia/Wernicke’s encephalopathy.
Tx:If neurological symptoms, 100 mg/d IV for 7-14 days , then 10 mg PO QD

43
Q

Vit A def 52-69% def after BPD, 10% after RYGB-sx?

A

visual difficulties at night

44
Q

Sx of Zinc def 5

*can cause impaired Folic Acid absorption

A

Mouth ulcers
dry scaly skin
acne

Hair loss
hypogonadism

45
Q

Sx of Mg deficiency 5

A 
fatigue
dizziness
weakness
muscle twitches
cramps
46
Q

Selenium deficiency 3

A

fatigue
hypothyroidism
cardiomyopathy (Keshan disease)

47
Q

Symptoms of protein malnutrition 3

A

edema/anasarca
hair loss
muscle wasting

*check albumin/pre-albumin, lowest about 1-2 years after surgery

48
Q

Surgery related hormone changes that promote satiety 3

A
  1. GLP-1 enhanced basally and post-prandially with bypass
  2. Ghrelin is reduced in bypass and sleeve
  3. PYY is elevated post-prandially in bypass and sleeve
49
Q

Managing pre-op diabetes meds 3

A
  1. Reduce long acting insulin by 60% initially during the 1-2 wk preop liquid diet
  2. Use higher blood glucose levels for further titrations 140-180
  3. if not on insulin, consider dropping hypoglycemics
50
Q

Meds to consider changing for malabsorptive patients 3

A
  1. Extended release formulations
  2. Coumadin
  3. OCPs
51
Q

Post-op labs for gastric bypass 14

A 
CBC
glucose
LFT
lipids
iron studies
ferritin
vitamin B12 (or elevated MMA >0.4)
Vit D25
metabolic panel (lytes)
albumin
pre-albumin
RBC-folate
intact PTH
Calcium
Optional thiamine, vitaminA , Zn, copper/ceruloplasmin

Annual BMD until stable

52
Q

Adolescent weight loss surgery
Criteria other than social/psychological 2
Strong indicators 4

A

Tanner stage IV or V, 95% bone growth

Strong indicators
T2DM
OSA
Non-alcoholic steatohepatitis
Pseudotumor cerebri
53
Q

Adolescent gastric bypass benefit

*sleeve recommended in pediatric algorithm

A

56% EBW weight loss at 10 years ( EBW? )

Lower complication rates than adults, 5.5%

54
Q

Pregnancy after WLS pro/cons

*wait a year after surgery, supplement folate

A

Reduced GDM, LGA

Increased SGA,Preterm birth, Still birth

55
Q

Intragastric balloons-criteria, duration, TWL, serious AE

A 
BMI 30-40 with comorbids
Place for 6 months then remove
12% TWL at removal
10.5% incidence serious AE
*trend toward weight regain after 3 years
56
Q

Plenity/Gelesis 100 - % achieving 5% TBW lost at a year

A

33%

57
Q

What is considered inadequate WL or weight regain post-bariatric surgery?

A

<20% WL

>15% weight gain

58
Q

What percentage of people have significant weight gain within 2-5 years after surgery?

A

25-35%

59
Q

What are the most common type of kidney stones in obese patients?

A

oxalate

60
Q

Symptoms signs of Cu deficiency \
*can occur with Fe deficiency, as it is involved with iron metabolism

Labs 3

Imaging 1

Symptoms groupings 2

Risk factors 2

A
  1. Normocytic, MICROCYTIC anaemia
  2. Ringed sideroblast
  3. Vacuoles in some marrow
  4. MRI T2 imaging increased in dorsal column

Progressive sensory ataxia with spastic gait
Weakness fatigue

At risk- excess zinc intake, bariatric surgery

61
Q

Gastro-gastric fistula.

When does it develop, sx

A

> 30 days post bypass surgery
Non healing ulcer results in opening between gastric pouch and remaining stomach.
Sx-increased capacity to ingest and absorb food, often with suboptimal weight loss or weight gain

Bariatric surgery (5 decks)

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