Surgery

Question 1

Enhanced recovery after bariatric surgery (ERABS)

Answer 1

Preoperative carb loading to decrease protein catabolism and insulin resistance as well as faster bowel function recovery (1)
- Surgery related - IS, breathing exercises, leg exercises, PPI

Question 2

Novel Devices and Procedures

Answer 2

Endoscopic bariatric therapies are in question

Intragastric balloons may be better for patients with lower BMI (30-35 with comorbids)

Question 3

Revisional WLS

Answer 3

Benefits - may not yield the same results as first time

RIsks - Complication rates are much higher, extended pattern of compliance is needed before proceeding

Question 4

Alcohol abuse and bariatric surgery

Answer 4

There is increased risk of alcohol use disorder following gastric bypass because there is accelerated absorption and longer time to alcohol elimination following bypass.

Question 5

Malabsorptive Procedures

Answer 5

Duodenal Switch (BPD-DS)- sleeve gastrectomy with biliopancreatic diversion; produces severe malabsorption
Loop Duodenal Switch (SADIS or SIPS) - bypasses about half of the small intestine with sleeve gastrectomy
Fewer complications with SIPS; BPD-DS/SIPS excess WL is about 80% at 10 yrs; Reserved for severe obesity (BMI >50); SIPS/SADIS emerging as the more common mainstream choice.

Question 6

BMI > 50 (Best choice WLS)

Answer 6

SIPS or RNY

Question 7

Type II DM (Best choice WLS)

Answer 7

SIPS or RNY

Question 8

Hx of pending organ transplant

Answer 8

Sleeve (SG)

Question 9

Vitamin deficiency that presents with neuropathy, megaloblastic anemia (b12 like)

Answer 9

Copper deficiency

Question 10

Fat Soluble Vitamins

Answer 10

ADEK

Question 11

Most likely to present with post-op vomiting, lower extremity weakness/neuropathy and nystagmus/diplopia

Answer 11

Thiamine deficiency

Question 12

Major threat for pregnant women and can cause neural tube defects

Answer 12

Folate deficiency

Question 13

The most common deficiency after gastric bypass

Answer 13

Iron deficiency anemia

Question 14

Dumping Syndrome

Answer 14

Rapid emptying of hypertonic carb load into the small bowel; symptoms - abdominal pain, cramping, flushing, palpitations, diaphoresis, tachycardia; early - <1 hr iwth distention of small bowel; late - 1-3 hours - hyperglycemia followed by hypoglycemia; prevented by dietary changes, avoid refined carbs

Question 15

Vitamin Supplements

Answer 15

MVI with iron, calcium citrate, Vitamin D3, B-complex vitamins
RNY - B-12 IM monthly, folate 400 mcg daiy
Malabsorptive procedures - check copper, zinc, selenium

Question 16

Later complication, bariatric surgery 1-2 years ago, now with abdominal pain, n/v, or nonspecific symptoms; CT scan or KUB shows…

Answer 16

“swirl sign” – INTERNAL HERNIA, more common after bypass type procedures

Question 17

Recent gastric bypass, presents with dysphagia, solid food intolerance, excessive weight loss (or poor weight loss); EGD or UGI shows…

Answer 17

Anastomotic stricture/stenosis, Treat with balloon dilation; rarely surgical revision

Question 18

RNY surgery, abdominal pain, n/v, GI bleeding, May have smoking, ETOH, Caffeine, NSAIDs, or steroid exposure, EGD shows…

Answer 18

Marginal Ulcers; Treat with PPI, sucralfate, improve nutrition

Question 19

Complication after bariatric surgery within in the first few days up to 2 weeks; tachycardic patient, leukocytosis, oliguria, fever, imaging shows L pleural effusion

Answer 19

LEAK!! May be managed by IR drainage, however, if unstable then needs resuscitation and OR

Question 20

Patient after long, complicated WL surgery in ICU; low urine output, “dark urine”

Answer 20

Check CPK level, myoglobin in urine; Dx: Rhabdomyolysis; Treat wtih supportive care, fluids

Question 21

30 Day Mortality Rate

Answer 21

BPD/DS (highest) > Gastric bypass/SADIS > Sleeve (lowest)

Question 22

Biggest Complication with Sleeve (SG)

Answer 22

New or worsening GERD (up to 20%)

Question 23

Severe baseline nutritional deficiencies

Answer 23

Sleeve (SG)

Question 24

Higher preoperative cardiopulmonary risk

Answer 24

Sleeve (SG)

Question 25

Kidney stones

Answer 25

Sleeve Gast (SG)

Question 26

GERD (Best choice WLS)

Answer 26

RNY

Question 27

Sleeve Gastrectomy (SG)

Answer 27

Usually 1st stage procedure to bypass, now primary weight loss (Most common procedure in US); removes 75-80% of the greater curvature of the stomach, preserves the pylorus, stomach 60-100 ml; very little malabsorption, Ghrelin is decreased (hunger decreased); full recovery in 2-3 weeks; 55-70% EWL

Question 28

Laparoscopic Adjustable Gastric Banding (LAGB)

Answer 28

Band creates a small stomach pouch that fills with a little food, helps suppress appetite, lowest mortality rate, least invasive surgical approach, adjustable/reversible, low malnutrition risk, quick surgery, full recovery < 2 weeks. 35-40% EWL with >40% regain most of their weight (this is why procedure is becoming historical)

Question 29

Gastric bypass (Roux-n Y or GBP)

Answer 29

Mostly restrictive, some malabsorption; 60-70% of patients will have lost at least 50% of their excess weight and kept it off at 10 years; Rapid initial weight loss, laparoscopic, full recovery in 4-6 weeks; 65-80% EWL with 20% regain most of their weight long term

Question 30

Relative Contraindications to WLS

Answer 30

Hx of substance abuse or eating disorder
Hx of psychiatric hospitalization in the past year, suicidal ideation, or major untreated/unresolved psychiatric problem
Patients to ill to undergo surgery
Women who are looking to become pregnant within 12 months

Question 31

Who is a candidate for Weight Loss Surgery (WLS)?

Answer 31

BMI > or = 40
BMI > or = 35 with an obesity related comorbidity (DM, OSA, HTN, etc)
*consider in 30-34.9 with comorbidity based on the American Society of Metabolic and Bariatric Surgery

Question 32

BMI > 50 (Best choice WLS)

Answer 32

SIPS or RNY