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Flashcards in 34 Introduction to Bariatric Surgery Deck (13):
1

Criteria for Weight Loss Surgery

  • considered when/
  • only offered to individuals who/

  • considered only when all other options have been exhausted.
  • only offered to individuals who are medically considered to be morbidly obese, such as those who:
    • Have a body mass index (BMI) greater or equal to 35, with one or more significant obesity-related conditions including:
      • High blood pressure
      • Diabetes
      • Arthritis
      • Sleep apnea
      • High cholesterol
    • Have a BMI greater than 40, regardless of other medical conditions
    • Are 14 to 75 years of age (site specific, with some exceptions)
    • Have a history of multiple failed attempts with diet plans, behavioral changes, and medical therapy
    • Have realistic expectations and motivations
    • Are capable of understanding the procedure and implication
    • Understand and accept the operative risks
    • Are committed to following the diet, vitamin supplementation, exercise program, and follow-up necessary for health and weight maintenance

2

Deciding whether to undergo bariatric surgery

  • The decision to undergo bariatric surgery
  • Commitment to Lifestyle Change
  • Other Medical Conditions

  • The decision to undergo bariatric surgery
    • complex and intensely personal, with many factors to take into account.
    • For individuals who are not morbidly obese, the risk of surgery far outweighs the expected health benefits of the weight loss.
    • Bariatric surgery is not performed for cosmetic reasons.
  • Commitment to Lifestyle Change
    • Bariatric or weight loss surgery is only effective when used in combination with diet and exercise.
    • You must be willing to comply fully with all recommended lifestyle changes (attitude, healthy eating, and physical activity).
  • Other Medical Conditions
    • Diseases associated with morbid obesity often lead to significant and permanent damage to one or more organ systems.
    • Sleep apnea commonly affects Lungs
    • Congestive failure or coronary artery disease commonly affects Heart
    • Diabetes and high blood pressure commonly affects Kidneys
    • Stress and arthritis commonly affects Bones and joints

3

Deciding whether to undergo bariatric surgery

  • Age
  • Mortality

  • Age
    • surgery candidates are between the ages of 14 and 75
    • higher level of attention for those who are at the high and low ends of the age spectrum.
    • Each patient is evaluated as to his or her ability to tolerate surgery, both physically and emotionally.
    • Selected younger patients may be considered candidates for a surgical approach to weight loss, depending on their history, medical problems, understanding of the procedure, family support, and other factors.
  • Mortality
    • The overall 30-day mortality for bariatric surgical procedures is less than 1 percent.
    • Increased mortality is associated with older age (65 years and >) and male gender.
    • Chronic disease and super-obesity (BMI >50) contribute to an increased risk of death with bariatric surgical procedures.
    • The super-obese patients are at increased risk for wound infections, dehiscence, venous thromboembolism and are likely to have multiple severe obesity related medical comorbidities.

4

Types of bariatric surgery:
Roux-en-Y gastric bypass (p.13-15)

  • involves the creation of a small gastric pouch and an anastomosis to a Roux limb of jejunum that bypasses 75 to 150 cm of small bowel, thereby restricting food and limiting absorption.
  • the most common weight-loss procedure performed.

5

Types of bariatric surgery:
Laparoscopic adjustable gastric band (LAGB) (p.9-10)

  • a purely restrictive procedure that involves placement of an adjustable silicone band at near the gastroesophageal junction, limiting the amount of food consumed.
  • Restriction can be adjusted by injecting saline into an access port connected to the band.
  • the second most common weight-loss surgery performed in the United States.
  • has the lowest mortality rate among all bariatric procedures.

6

Types of bariatric surgery:
Laparoscopic sleeve gastrectomy (LSG) (p.11-12)

  • a restrictive procedure initially developed as part of a staged approach for high-risk super-obese patients.
  • Sleeve gastrectomy involves creating a "sleeve" of stomach and removes a large portion of the greater curvature of the stomach leaving a small tube along the lesser curvature.
  • produces a decrease in ghrelin levels for up to a year, which may reduce the desire for food.

7

Complications

  • Bleeding--Significant bleeding after gastric bypass has been described in 0.6 to 4.0 percent of patients. A higher rate of postoperative gastrointestinal bleeding was observed following laparoscopic versus open GBP in a prospective randomized study. Early bleeding typically occurs from one of the surgical anastomotic and/or staple lines.
  • Wound infection-- significantly more frequent with open (10 to 15 percent) than laparoscopic (3 to 4 percent) gastric bypass procedures.
  • Leaks-- The rate of anastomotic leak in RYBG is 1.5 to 6 percent and can be as high as 35 percent in revisional surgery. If not diagnosed in a timely fashion, the mortality rate can be as high as 15 percent.
  • Pulmonary embolism and deep venous thrombosis--Pulmonary embolism (PE) remains the most common cause of mortality in the perioperative period after weight-loss surgery and occurs in 0.2-1% of patients. It can account for more than 50 percent of deaths. The most common risk factors associated with fatal PE include severe venous stasis disease, BMI >60, truncal obesity, and obesity-hypoventilation syndrome
  • Cardiovascular complications--Cardiovascular complications, including myocardial infarction and cardiac failure, are a common cause of mortality in the perioperative period. An analysis of 13,871 morbidly obese patients from a national registry reported that the mortality from cardiovascular events ranged from 12.5 to 17.6 percent.
  • Pulmonary complications--Respiratory failure accounts for 11.3 percent of perioperative mortality after weight-loss surgery
  • Postoperative hypoglycemia

8

Specific later complications:
Roux-en-Y gastric bypass (RYGB):
Dumping syndrome

  • Dumping syndrome
    • can occur when/
    • may contribute to/
  • Early dumping syndrome
  • Late dumping syndrome

  • Dumping syndrome
    • can occur when high levels of simple carbohydrates are ingested.
    • may contribute to weight loss in part by causing the patient to modify his/her eating habits. 
  • Early dumping syndrome
    • has a rapid onset, usually within 15 minutes.
    • the result of rapid emptying of food into the small bowel.
    • Due to the hyperosmolality of the food, rapid fluid shifts from the plasma into the bowel occur, resulting in hypotension and a sympathetic nervous system response.
    • Patients often present with colicky abdominal pain, diarrhea, nausea, and tachycardia.
    • Patients should avoid foods that are high in simple sugars.
    • Behavioral modification, such as small, frequent meals, and separating solids from liquid intake by 30 minutes, are also advocated.
    • Usually, early dumping is self-limiting and resolves within 7 to 12 weeks.
  • Late dumping syndrome
    • a result of the hyperglycemia and the subsequent insulin response leading to hypoglycemia that occurs 2 to 3 hours after a meal.
    • Patients present with dizziness, fatigue, diaphoresis and weakness.
    • The treatment is similar to early dumping syndrome.

9

Specific later complications:
Roux-en-Y gastric bypass (RYGB):
Additional complications

  • Metabolic and nutritional derangements/ Vitamin and mineral deficiencies
  • Stomal stenosis
  • Marginal ulcers
  • Cholelithiasis
  • Ventra/l incisional hernia (open surgery)
  • Internal hernias
  • Postoperative hypoglycemia
  • Change in bowel habits
  • Failure to lose weight and weight regain

10

Specific complications

  • Specific complications of laparoscopic adjustable gastric banding:
  • Specific complications of laparoscopic sleeve gastrectomy

  • Specific complications of laparoscopic adjustable gastric banding:
    • Stomal stenosis
    • Port infection
    • Band erosion
    • Band slippage and gastric prolapse
    • Port malfunction
    • Esophagitis
    • Esophageal dilatation
  • Specific complications of laparoscopic sleeve gastrectomy:
    • bleeding, narrowing or stenosis of the stoma, and leaks.

11

Post-surgical Management

  • Bariatric surgery has been shown to improve anthropometric measures (weight, BMI, waist circumference) and to improve blood pressure, diabetes, cholesterol and other health parameters.

12

Nutritional Management

  • Following bariatric surgery, patients experience/
  • Early diet
  • The immediate postoperative diet recommendations emphasize/
  • Nutritional deficiencies that occur after bariatric surgery depend significantly on the type of surgery performed. 
    • Restrictive procedures
    • Malabsorptive procedures
  • Nutritional labs

  • Following bariatric surgery, patients experience significant improvements in medical comorbidities and changes in hunger and/or satiety related to alterations in food pathway.
  • Early diet
    • based on a staged approach with emphasis on texture and nutrient needs.
    • A large variation in food tolerances is seen, and patients who have undergone RYGB or LAGB benefit from well-planned dietary advancement, both to ensure proper healing of the surgery and to develop life-long healthy eating habits .
  • The immediate postoperative diet recommendations emphasize hydration and protein intake.
    • To avoid food impaction, patients are started on a liquid diet immediately following surgery.
  • Nutritional deficiencies that occur after bariatric surgery depend significantly on the type of surgery performed.
    • Restrictive procedures such as gastric banding are the least likely to cause nutritional deficits, since none of the intestine is bypassed.
    • Malabsorptive procedures such as biliopancreatic diversion or mixed restrictive/malabsorptive procedures (e.g., Roux-en-Y gastric bypass) can result in serious nutritional problems when patients do not take required supplements after surgery.
      • Vitamins and minerals that are commonly deficient in this circumstance include vitamin B12, calcium, vitamin D, thiamine, folic acid, iron, zinc, and magnesium.
      • Rare ocular complications have been reported with hypovitaminosis A.
  • Nutritional labs should be drawn at 6, 12 months then yearly indefinitely.

13

Laparoscopic vs. Open Surgery (p.16)

  • Smaller scars
  • Less pain
  • Quicker recovery
  • Fewer hernias / infections
  • Same weight loss