Indications for Bariatric surgery?3
1. BMI ≥ 40 kg/m2 without comorbidities
2. BMI 35-39.9 kg/m2 with comorbidity
3. BMI 30-34.9 kg/m2 (w/specific comorbodities)
BMI 35-39.9 kg/m2 with comorbidity which comorbities? 13
1. Type 2 DM 2. OSA
5. Obesity-hypoventilation syndrome (OHS)
6. Pickwickian syndrome (OSA+OHS)
7. Nonalcoholic steatohepatitis (NASH)
8. Pseudotumor cerebri
10. Venous stasis disease
11. Severe urinary incontinence
12. Debilitation arthritis
13. Impaired quality of life
BMI 30-34.9 kg/m2 with what comorbidites? 2
1. Uncontrollable Type 2 DM
2. Metabolic syndrome Lack of evidence to support long term benefit in this group
Contraindications to bariatric surgery? 10
1. History of bulimia
2. Age > 65 or less than 18
3. For lipid or glycemic control
4. For CV risk reduction
5. Untreated major depression or psychosis
6. Binge-eating disorders
7. Current drug or alcohol abuse
8. Severe cardiac disease with prohibitive anesthetic risks
9. Severe coagulopathy
10. Inability to comply with requirements including (life-long nutritional supplements) & dietary changes**
Preoperative assessment includes what? 3
3. Anesthetic risk
Preoperative assessment requires a team approach Who? 5
2. Medical bariatric specialist
4. Clinical nurse specialist
Goals of the psychologic assessment 4
1. Is the patient able and willing to make the necessary changes?
2. Identification of mental disorders
3. Social history in regards to previous weight loss attempts, physical activity, substance abuse, compulsive eating
4. Does the patient have the cognitive ability to do this and the support to carry it through?
Components of the psychological assessment 4
3. Current life situation
Medical assessment includes? 2
Complete history and physical exam
Mechanisms of weight loss with surgery 3
Restrictive surgeries do what? What are the three general processes?
Limit caloric intake by reducing the stomach's capacity:
3. Creation of a proximal gastric outlet
Specific Restrictive surgeries? 3
1. Vertical banded gastroplasty
2. Laparoscopic adjustable gastric banding
3. Sleeve gastrectomy
Malabsorptive surgeries do what? How is this accomplished? 2
Decrease the effectiveness of nutrient absorption by shortening the length of the functional small intestine:
1. bypass of the small bowel absorptive surface area
2. diversion of the biliopancreatic secretions that facilitate absorption
Malabsorption surgeries 2
1. Jejunoileal bypass
2. Duodenal switch operation
Combination restrictive/malabsorptive surgeries 3
1. Roux-en-Y gastric bypass (RYGB)
2. Biliopancreatic diversion
3. Biliopancreatic diversion with duodenal switch
3 Most common bariatric surgeries
1. Roux-en-Y gastric bypass (47%)
2. Sleeve gastrectomy (28%)
3. Laparoscopic adjustable gastric band (18%)
Roux-en Y gastric bypass (RYGB)
Most commonly performed bariatric surgery in the US
47% of weight loss surgeries done in 2011
1. Gastric pouch is how big?
2. Gastric pouch attached to a section of small bowel ______cm in length (gastrojejunostomy)
3. Cut ends of the _____________and the __________are then connected 75 to 150 cm distal from the gastrojejunostomy
1. Gastric pouch less than 30 ml
2. 75-150 cm in length (gastrojejunostomy)
3. biliopancreatic limb, the Roux limb
Major digestion and absorption of nutrients occurs where?
in the common channel where pancreatic enzymes and bile mix
Weight loss mechanism
1. What part of restrictive?
2. What contributes to the malabsorption part?
3. What suppressses the appetite?
4. What two substances are increased post bypass? and what will this promote?
1. Small pouch is restrictive
2. There is malabsorption because of the “removed” small bowel
3. Ghrelin inhibition (suppresses appetite)
4. GLP-1 and CCK increased post bypass (may promote an anorectic state)
Gastrojejunostomy can result in ____________with high sugar meals
1. Dumping syndrome
2. lightheadedness, nausea, diaphoresis and/or abdominal pain, and diarrhea
Expected weight loss with RYGB
Up to 70% of extra weight in 2 years
Describe the Sleeve gastrectomy?
Second most common weight loss surgery performed worldwide
28% of all procedures in 2011
1. Most of the what is removed?
2. Advantages? 2
3. New stomach is resistant to what?
4. Contains a few _______producing cells
1. Most of the greater curvature of the stomach is removed
2. Safer and technically less difficult to perform than RYGB
3. New stomach is resistant to stretching without the fundus
Weight loss mechanism: for sleeve gastrectomy?
2. Alterations in gastric motility
3. Decreased ghrelin levels
4. Increased GLP-1 and PYY (promote less hunger)
Expected weight loss with sleeve gastrectomy?
60% of excess weight lost in 2 years
Laparoscopic adjustable gastric band surgery
18% of bariatric surgeries done in 2011
1. What is the lap band and where is it placed?
2. How does it work?
3. Goal of band adjustments? 2
1. Soft silicone ring connected to an infusion port placed in the subcutaneous tissue
2. Ring is inflated with saline to cause variable degrees of restriction
3. Goal of band adjustments
-Allow a cup of dried food
-Satiety for at least 1.5 to 2 hrs after a meal.
1. Lowest mortality rate among bariatric pts?
1. Lap band
Weight loss mechanism for Lap Band?