Bariatric Surgery

Question 1

Classification of Body Weight & Obesity

Answer 1

Primary & secondary obesity

Question 2

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• Chromosomal & congenital anomalies
• Metabolic problems
• CNS lesions & disorder(s)

Answer 2

Secondary obesity

Question 3

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• Excess caloric intake for the body’s metabolic demands

Answer 3

Primary obesity

! The majority of obese people have primary obesity (they’re eating too much & exercising too little; also are eating foods that are nutritionally deficient)

Question 4

Patient Assessment

• Body mass index (BMI)
• Waist circumference
• Waist-to-hip ratio
• Determination of body shape

Answer 4

> BMI & waist circumference are widely used; they’re cost-effective & reliable in practice settings

Question 5

Cardiovascular Problems

• Obesity is a significant risk factor for CVD

> Android obesity pts @ greater risk
* ↑ LDLs
* High TG’s
* ↓ HDLs

Answer 5

• Obesity is assoc w/HTN which occurs b/c of inc circulating blood volume, abn vasoconstriction, inc inflammation, & inc in sleep apnea which raises BP
• Altered lipid metabolism & HTN can lead to long-term risk of heart dz & CVA; excess body fat can also lead to chronic inflammation throughout body esp in blood vessels which can in turn inc risk of HD

Question 6

Diabetes Mellitus

Type 2 diabetes
* Hyperinsulinemia
* Insulin resistance
* Glucose intolerance

! Weight loss & exercise improve glucose control

Answer 6

• More than 80% of people w/type 2 DM are obese or overweight

! A reduction of 7% of a person’s weight can reduce the risk of diabetes by 58%

Question 7

GI & Liver Problems

• GERD
• Gallstones
• NASH
  > Can eventually lead to cirrhosis
  ! Weight loss can improve

Answer 7

• Gallstones occur d/t supersaturation of bile w/cholesterol
• NASH occurs when lipids deposit in the liver, leading to a fatty liver
  > Assoc w/elevated hepatic glucose production & can eventually lead to cirrhosis & be fatal

Question 8

Respiratory & Sleep Problems

• Sleep apnea
  > Snoring & hypoventilation
• Obesity hypoventilation syndrome
  > Reduced chest wall compliance
  > ↑ work of breathing
  > ↓ total lung capacity & functional residual capacity

Question 9

The level of __ falls in patients who are sleep deprived, thus promoting appetite

Answer 9

leptin

Question 10

Musculoskeletal Problems

• Osteoarthritis
  > Stress on weight-bearing joints (knees & hips)

> Obesity triggers inflammatory mediators

Answer 10

> Cartilage deterioration

> ↑ incidences of hyperuricemia & gout

Question 11

Cancer

• Obesity is 1 of the most important, known preventable causes of cancer
  > Breast, endometrial, kidney, colorectal, & GB cancers are linked to excess body fat

Answer 11

• 20% in women; 15% in men

Question 12

Psychosocial Problems

• Stigmatization
  > Low self-esteem
  > Social isolation
  > Depression

Answer 12

• Discrimination in employment, education, & healthcare

Question 13

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• A viable & popular option for treating obesity
• Currently the only treatment found to have a successful & lasting impact on sustained wt loss for severely obese individuals

Answer 13

Bariatric Surgery

Question 14

Criteria for surgery

• BMI ≥ 40 kg/m2

Answer 14

• BMI ≥ 35 kg/m2 w/1 or more obesity-related complications
  > HTN, type 2 DM, HF, sleep apnea

Question 15

Must be screened for

• Psychological, physical, & behavioral conditions that have been assoc w/poor surgical outcomes
• Illnesses known to reduce life expectancy & not likely to be improved w/weight reduction

Answer 15

• Pts are not good candidates for bariatric surgery if they have untreated depression, binge-eating disorders, & drug & alcohol abuse that may interfere w/the commitment req’d to lifelong behavioral changes

Question 16

Other criteria -

• Advanced cancer
• End-stage renal, liver, and cardiopulmonary dz
• Severe coagulopathy
• Inability to comply w/nutritional requirements

Question 17

Bariatric Surgery - 3 broad categories

• Restrictive
• Malabsorptive
• Combination of restrictive & malabsorptive

Question 18

___ surgery

The length of the SI is decreased, so there is less food absorbed

Answer 18

Malabsorptive

Question 19

___ surgery

The stomach is reduced in size; there is less food eaten

Answer 19

Restrictive

Question 20

A majority of these procedures are done laparoscopically, thus decreasing any postop complications or recuperation (as opposed to having an open procedure)

Answer 20

There are less wound infections, shorter hospital stays, & a faster recovery period

Question 21

• Adjustable gastric banding (AGB)
• Vertical sleeve gastrectomy
• Vertical banded gastroplasty (VBG)

Answer 21

• Biliopancreatic diversion (BPD) w/duodenal switch
• Roux-en-Y bypass

Question 22

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• Most common procedure
• Limits stomach size w/an inflatable band around fundus of the stomach
  > Connected to a subcutaneous port then can be inflated or deflated to meet pt’s needs as wt is lost

! Creates a sense of fullness; can be modified or reversed @ a later date if necessary

Is this restrictive, malabsorptive, or both?

Answer 22

Adjustable gastric banding (AGB)

restrictive

Question 23

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• 85% of the stomach is removed; NOT reversible
• Stomach function is preserved
• Results in elimination of hormones produced in the stomach that stimulate hunger (?)

Is this restrictive, malabsorptive, or both?

Answer 23

Vertical sleeve gastrectomy

ghrelin

restrictive

! Pts who are morbidly obese lose more wt w/this procedure

Question 24

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• Has low complication rates
• Excellent pt tolerance
• Food bypasses 90% of stomach, duodenum, & a small segment of jejunum

Is this restrictive, malabsorptive, or both?

Answer 24

Roux-en-Y surgical procedure (RNYGB)

both

Question 25

Roux-en-Y * Is a robotic-assisted surgical procedure; results in quick wt loss but is more invasive w/a risk of postop complications ! Most commonly called "gastric bypass"

Answer 25

* Parts of the stomach are bypassed so fewer calories are absorbed

Question 26

Combination Restrictive & Malabsorptive Surgery * __ __ is common >RYGB > Gastric contents empty too rapidly into the SI > Avoidance of sugary foods is recommended

Answer 26

Dumping syndrome

Question 27

Dumping syndrome * N/V, fainting, weakness, diaphoresis, & sometimes diarrhea

Answer 27

> Eat smaller portions that are low in sugar; don't drink liquids w/meals; we want to slow the process down

Question 28

Preoperative Care * Determine > Assistive devices currently in use > Past & current health info (comorbidities inc risk of complications) * A team approach may be necessary (cardiologist, pulmonologist)

Answer 28

* Have room ready for pt

Question 29

* Practice cough & DB, turning, & positioning procedures > Teach spirometer use > Arrange for CPAP if used @ home

Answer 29

* Obtain longer IV catheter * May have NG tube placed

Question 30

Postoperative Care * Close observations for complications * Transfer w/specially trained personnel > Stabilize airway > Manage pain > Elevate HOB to 30-45°

Answer 30

* Evaluate for re-sedation * Be on the lookout for thrombus formation, anastomosis leak, & electrolyte imbalances > Ensure a patent airway when returning from surgery

Question 31

* Diligent turning & ambulating > Excess adipose tissue compresses chest & abdomen ! Causes CO2 retention ! Hypoxemia, PHTN, polycythemia

Answer 31

* Risk for DVT > Anti-embolism stockings, SCD's, low weight heparin * Infection (bacterial/fungal), dehiscence, delayed healing

Question 32

Special Considerations: Postop Care * Considerable abdominal pain > Medicate as needed > Assess for anastomosis leaks > Evaluate wound condition closely > Attentive to placement of NG tube > Careful transition to new diet

Answer 32

> Monitor drainage & dressings; incision area > If a pt vomits w/an NG tube in place, the tube may need to be repositioned; notify the surgeon immediately

Question 33

Ambulatory & Home Care * Following bariatric surgery, pts find it challenging to maintain a prescribed diet > Pt now has reduced intake b/c of anatomic changes > Attention to nutrition is important to prevent early &/or late complications

Answer 33

! Diet should be high in protein & low in carbs & fat; 6 small feedings daily; no fluids w/meals; restricted to <1000 mL/day ! In the late recovery phase we may see peptic ulcer formation, dumping syndrome, & small bowel obstructions

Question 34

* Long-term follow-up care is important for physical & psychological reasons > Old diet patterns > Issues r/t the return of fertility in women > New body image

Answer 34

Cosmetic Surgeries * Ideal candidates have *achieved weight reduction* & *have excess skin folds or fat* * Chooses surgery for cosmetic reasons; lipectomy/liposuction

Question 35

Evaluation - Expected Outcomes * Long-term wt loss * Improvement in obesity-related co-morbidities * Integration of healthy practices into lifestyle

Answer 35

* Improved self-image * Monitor for possible adverse effects

Question 36

Obesity: *Gerontologic Considerations* * Increased prevalence of obesity > Decreased energy expenditure contributes to inc body fat

Answer 36

> Exacerbates age-related problems * ↓ mobility, urinary continence, hypoventilation, sleep apnea * ↓ quality of life * ↓ life expectancy by 6-7 yrs