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Bariatric Surgery Flashcards

(73 cards)

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1
Q

Indications for Bariatric Surgery

A

BMI > 40 without comorbidities
BMI 35-39.9 with comorbities
BMI 30-34.9 with uncontrolled type 2 DM or metabolic syndrome

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2
Q

Comorbidities with a BMI 35-39.9 for Bariatric Surgery

A 
DM2
OSA
HTN
Hyperlipidemia
Obesity-hypoventilation syndrome (OHS)
Pickwickian syndrome (OSA+OHS)
Nonalcoholic steatohepatitis (NASH)
Pseudotumor cerebri
GERD
Venous stasis disease
Severe urinary incontinence
Debilitating arthritis
Impaired QOL
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3
Q

Contraindications for Bariatric Surgery

A

Hx of bulimia

Age >65 or

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4
Q

Preoperative Assessment for Bariatric Surgery

A

Psychological

Medical anesthetic risk

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5
Q

Preoperative Assessment for Bariatric Surgery

A 
Nutritionist
Medical bariatric specialist
Psychologist/Psychiatrist
Clinical nurse specialist
Surgeon
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6
Q

Components of the Psychological Assessment

A

Behavioral
Cognitive/emotional
Current life situation
Expectations

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7
Q

Mechanisms of Weight Loss with Surgery

A

Restriction
Malabsorption
Both

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8
Q

Define Restrictive Surgery

A

Limit caloric intake by reducing the stomach’s capacity via resection, bypass, or creation of a proximal gastric outlet

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9
Q

Examples of Restrictive Surgeries

A

Vertical banded gastroplasty
Laparoscopic adjustable gastric banding
Sleeve gastrectomy

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10
Q

Examples of Malabsorptive Surgeries

A

Jejunoileal bypass

Duodenal switch operation

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11
Q

Define Malabsorption Surgeries

A

Decrease the effectiveness of nutrient absorption by shortening the length of the functional small intestine by bypassing of the small bowel absorptive surface area or diversion of the biliopancreatic secretions that facilitate absorption

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12
Q

Examples of Combination Surgeries

A

Roux-en-Y gastric bypass
Biliopancreatic diversion
Biliopancreatic diversion with duodenal switch

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13
Q

Top 3 Bariatric Surgeries

A

Roux-en-Y
Sleeve gastretomy
Laparoscopic adjustable gastric band

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14
Q

Roux-en-Y Surgery

A

Gastric pouch

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15
Q

Roux-en-Y Weight Loss Mechanism

A 
Pouch restrictive
Malabsorption of "removed" small bowel
Gastrojejunostomy can result in dumping syndrome
Ghrelin inhibition
GLP-1 & CCK increased post bypass
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16
Q

Symptoms of Dumping Syndrome

A 
Lightheadedness
Nausea
Diaphoresis
Abdominal pain
Diarrhea
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17
Q

What does insulin do?

A

Stimulates insulin synthesis

Suppresses appetite

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18
Q

What does CCK do?

A

Gallbladder contraction
Stimulates gastric emptying
Suppresses appetite

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19
Q

Expected Weight Loss with RYGB

A

Up to 70% in 2 years

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20
Q

Sleeve Gastrectomy

A

Great curvature of stomach is removed
Safer & technically less difficult that RYGM
Resistant to stretching

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21
Q

Weight Loss Mechanism of a Sleeve Gastrectomy

A

Restrictive
Alterations in gastric motility
Decreased gherkin levels
Increased GLP-1 & PYY

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22
Q

Expected Weight Loss for a Sleeve Gastrectomy

A

60% weight lost in 2 years

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23
Q

Lap Band

A

Soft silicone ring connected to infusion port

Ring inflated with saline to vary the restriction

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24
Q

Goal of Lap Band Adjustments

A

Allow a cup of dried food

Satiety for 1.5-2 hours

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25
Weight Loss Mechanism for lap Band
Restrictive
26
Expected Weight Loss with Lap Band
50-60% at 2 years
27
What do you need to monitor post bariatric surgery?
Weight Blood pressure Glycemic control Nutrient deficiencies
28
Weight & Blood Pressure Monitoring
``` Every visit Watch for hypotension Check every 4-6 weeks for 6 months Check at 9 & 12 months Check annually ```
29
Macronutrient Needs
Protein Carbs Fats RYGB doesn't cause significant macronutrient deficiencies
30
Micronutrient Deficiency in a Lap Band Procedure
Folate deficiency
31
Micronutrient Deficiency in a Sleeve Gastrectomy
B12
32
Micronutrient Deficiency in a RYGB
Vitamin A, D, E, K, B1, B12 Iron, copper, zinc Folic acid, biotin, selenium
33
Routine Labs for Bariatric Surgery
``` CBC CMP Iron studies, ferritin B12 Lipids Vit. D, PTH Thiamine Folate Zinc Copper ```
34
Medication Management Post Surgery
Change from delayed release to immediate release DC DM meds & use insulin for glycemic control DC antireflex meds except after sleeve gastrectomy Contraceptive pills less effective Avoid NSAIDs
35
Factors that Affect Glycemic Control
400-800 kcal diet/day for 1st month Improvement in DM control DM remission can occur Exposure of jejunum to undigested nutrients
36
Late Complications
Cholelithiasis Nutritional deficiencies Neurologic complications Psychological complications
37
Complications of RYGB
``` Gastric remnant distention Stomal stenosis Internal hernias Short bowel syndrome Metabolic/nutritional derangements Renal failure Post-op hypoglycemia Change in bowel habits Failure to lose weight & weight regain Ventral incisional hernias ```
38
Signs/Symptoms Gastric Remnant Distention
``` Upper abdominal pain Hiccups LUQ tympany to percussion Shoulder pain Abdominal distention Tachycardia Shortness of breath Large gastric bubble on Xray ```
39
Define Gastric Remnant Distention
Gastric pouch severe distention secondary to mechanical obstruction or paralytic ileus
40
Treatment of Gastric Remnant Distention
Emergency surgery
41
Signs/Symptoms of Stomal Stenosis
N/V Dysphagia GE reflux inability to tolerate oral intake
42
Define Stomal Stenosis
Narrowing at the anastomosis
43
Work-up for Stomal Stenosis
Endoscopy or UGI series
44
Treatment of Stomal Stenosis
Endoscopic balloon dilation
45
Define Marginal Ulcers
Acid injury to the jejunum or associated with gastrogastric fistula
46
Causes of Marginal Ulcers
``` Poor tissue perfusion Excess acid NSAIDs H. pylori Smoking ```
47
Symptoms of Marginal Ulcers
Nausea Pain Bleeding and/or perforation
48
Diagnostics of Marginal Ulcers
Upper endoscopy
49
Treatment of Marginal Ulcers
``` Acid suppression Sucralfate DC NSAIDs DC smoking Test & treat H. pylori ```
50
Signs/Symptoms of Acute Cholecystitis/ Cholelithiasis
``` RUQ pain R. shoulder pain/ pain in upper back N/V Fever Worse pain with inspiration Pain last longer than 6 hours Pain starts postprandial Tender RUQ on exam ```
51
How can acute cholecystitis/ cholelithiasis be prevented?
Post operative ursodiol
52
Diagnostics of Acut Cholecystitis/ Cholelithiasis
US
53
Treatment of Acute CHolecystitis/ Cholelithiasis
Cholectomy
54
What does short bowel syndrome result in?
Severe micro and macronutrient deficiencies
55
Treatment of severe cases of short bowel syndrome
Intestinal transplantation
56
Signs/Symptoms of Short Bowel Syndrome
``` 15 minutes postprandial: Colicky abdominal pain Diarrhea Nausea Tachycardia ```
57
When is early dumping syndrome prominent?
Post ingestion of simple carbs
58
Symptoms of Late Dumping Syndrome
Dizziness Fatigue Diaphoresis Weakness
59
Symptoms of Severe Hypoglycemia
Blackouts | Seizures
60
What can sever hypoglycemia be secondary to post bariatric surgery?
Insulinoma | Islet cell hypertrophy
61
Bowel changes post RYGB
Diarrhea | Loose stools
62
Bowel changes post gastric banding
Constipation
63
What can be occurring when a patient complaint is "I'm not losing weight" or "I'm gaining weight" after bariatric surgery?
Maladaptive eating patterns Gastrogastric fistula Gradual enlargement of the gastric pouch Dilation of the gastrojejunal anastomosis
64
Complications from Gastric Banding
``` Pouch dilation Stomal obstruction Band slippage, infection or erosion Incisional hernias Port-tubing disconnections Port infections Esophagitis Esophageal dilation ```
65
Symptoms of Stomal Obstruction
Persistent nausea Vomiting Inability to tolerate secretions or oral intake
66
What can stomal obstruction be secondary to?
Edema | Band being too tight
67
Diagnostic of Stomal Obstruction
UGI
68
Treatment of Stomal Obstruction
NG tube to decompress until edema subsides or surgery for band revision
69
Symptoms for Band Erosion
``` Infection Failure of weight loss N/V Epigastric pain Hematemesis ```
70
Diagnostic of Band Erosion
Endoscopy
71
Treatment of Band Erosion
Surgical removal
72
Most Common Sleeve Gastrectomy Complications
GERD Bleeding tenses of the stoma Leaks
73
What local factors impede gastric leaks from healing?
Inadequate blood supply at staple line Gastric-wall heat ischemia High intra-gastric pressure

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