23 Questions
What is benefit of bariatric surgery?
Improvement and resolution of insulin resistance, metabolic disease, comorbidities and decrease in morbidity rates
Match the different types of bariatric surgeries with their descriptors. This is a brief overview between restrictive and Malabsorptive.
Sleeve Gastrectomy = RESTRICTIVE. Reduces stomach reservoir, limits amount of food consumed. No manipulation of small intestines. Adjustable Gastric Banding = RESTRICTIVE. Reduces stomach reservoir, limits amount of food consumed. No manipulation of small intestines. Single Anastomosis Duodenal Switch = Malabsorptive. limits amount of nutrients absorbed by bypassing a portion of small intestines. Roux-en-Y Gastric Bypass = Malabsorptive. limits amount of nutrients absorbed by bypassing a portion of small intestines.
Match the CONTRAINDICATIONS with the bariatic surgery
Barrett’s Esophagus, Severe GERD, Achalasia = Sleeve Gastrectomy (SG) Drug/ETOH addiction, Hx of gastric ulcers, Crohn’s disease, uncontrolled gout = Roux-en-y Gastric Bypass (RYGBP) Drug/ETOH addiction, Barrett’s, Crohn’s disease/ UC, AI disease = duodenal switch Severe GERD, Barrett’s Esophagus, Achalasia = Adjustable Gastric Banding
What is the currently most performed bariatric surgery in the USA
Sleeve Gastrectomy (SG)
Match the surgery procedure to the surgery name
80% stomach resected and permanently removed from body = Sleeve Gastrectomy (SG) A small proximal gastric pouch is created and half of the jejunum is attached at this point. The other half of jejunum remains attached to "remnant" stomach and bile ducts. = Roux-en-Y Gastric Bypass Create a loose sleeve, tack loop of bowel from ileocecal to mesentery in RUQ and mobilize duodenum posteriorly to gastroduodenal artery, lastly, resect duodenum distal to pylorus = Biliopancreatic Diversion w/ Duodenal Switch Band placed across upper stomach: 1 cm below esophago-gastric junction, then secure band w/ 3-4 gastric sutures fixation of port within subcutaneous fat vs suture to muscle fascia = Adjustable Gastric Banding
A patient presents with nausea, vomiting, diarrhea, and feel very ill after eating a high fat meal with a surgical history of Roux-en-y Gastric Bypass. What is this called?
Dumping Syndrome
Match the PROs for each bariatric surgery type!
greater improvement in metabolic disease = Roux-en-Y Gastric Bypass Improves metabolic disease; maintains small intestinal anatomy; micronutrient deficiencies infrequent = Sleeve Gastrectomy (SG) Least invasive and removable = Adjustable Gastric Banding Greatest amount of weight loss and resolution of metabolic disease = Biliopancreatic diversion with duodenal switch (BPD-DS)
CONS of each type of bariatric surgery
no long term data = Laparoscopic sleeve gastrectomy increased risks of malabsorption complications = Roux-en-Y gastric bypass 20-40% 5 year removal rate = Gastric banding increased rate of macro and micro-nutrience deficiencies = Biliopancreatic diversion with duodenal switch (BPD-DS)
What patient is optimally suited for specific bariatric surgery?
Metabolic disease = Laparoscopic sleeve gastrectomy High BMI, GERD, T2DM = Roux-en-Y gastric bypass Lower BMI with no metabolic disease = Gastric banding High BMI, T2DM = Biliopancreatic diversion with duodenal switch (BPD-DS)
Barrier, Nexplanon, Depo-Provera, IUD recommended for 12-18 months for bariatric surgery (not OCP) as contraceptive.
True
After bariatric surgery, NSAIDS should be avoided for LIFE.
True
Accelerated pouch emptying, excess GLP1 production and excess insulin release leading to hypoglycemia that occurs after RYGB that is often marked by high variable post prandial glucose levels is called -
Hyperinsulinemic Post-prandial Hypoglycemia
Kidney and gallstones are NOT common metabolic post-bariatric surgery complications.
False
What are EARLY complications associated with bariatric surgery (<30 days)
A patient presents with abdominal pain, fever, tachycardia and leukocytosis 3-14 days post-op = Leak or Perforation Patient presents with Tachycardia, Hypotension, drop in H/H, Oliguria within 3 days of procedure = Bleeding Patient presents with Pain, excessive drainage, fever/chills, leukocytosis = Wound Infection a = a
When is small bowel obstruction most common to occur post-operative?
6 months
A patient c/o spitting up white foam 4-6 weeks after RYGBP. What is likely?
Stricture
Do not drink fluids ____ mins prior/after eating once you have had bariatric surgery.
30
At what BMI equal to or greater (regardless of comorbidities), does a patient qualify for bariatric surgery?
35
Individuals with _______ disease and BMI of 30-34.9 qualify for bariatric surgery.
metabolic
Individuals with _____ and BMI ≥30
T2DM
Individuals with BMI of 30–34.9 who do not achieve substantial weight loss or comorbidity improvement using nonsurgical methods QUALIFY for bariatric surgery.
True
is roux-en-Y gastric bypass restrictive or malabsorptive?
both
Among bariatric procedures, which surgery has the highest risk for nutritional deficiencies and severe protein malnutrition
Biliopancreatic diversion w/ duodenal switch
Study Notes
Benefits of Bariatric Surgery
- Bariatric surgery helps in weight loss and improves overall health
Types of Bariatric Surgeries
- Roux-en-Y Gastric Bypass: a restrictive and malabsorptive surgery
- Restrictive surgeries: reduce stomach capacity, limit food intake
- Malabsorptive surgeries: alter digestion, reduce nutrient absorption
- Other surgeries: Laparoscopic Adjustable Gastric Banding, Sleeve Gastrectomy, Biliopancreatic Diversion with Duodenal Switch
Contraindications for Bariatric Surgery
- Unstable psychological conditions
- Active substance abuse
- Untreated eating disorders
- Lack of commitment to lifestyle changes
Most Performed Bariatric Surgery in the USA
- Roux-en-Y Gastric Bypass
Surgery Procedures
- Roux-en-Y Gastric Bypass: creation of a small stomach pouch, attaching it to the small intestine
- Laparoscopic Adjustable Gastric Banding: placing an adjustable band around the stomach
- Sleeve Gastrectomy: removal of a portion of the stomach, forming a narrow sleeve
- Biliopancreatic Diversion with Duodenal Switch: rerouting of the small intestine, creating a bypass and sleeve-like structure
Patient Presentation
- Dumping syndrome: nausea, vomiting, diarrhea, and feeling ill after eating a high-fat meal, common in Roux-en-Y Gastric Bypass patients
Pros and Cons of Bariatric Surgeries
-
Roux-en-Y Gastric Bypass:
- Pros: high weight loss, improvement in comorbidities
- Cons: malnutrition, vitamin deficiencies, dumping syndrome
-
Laparoscopic Adjustable Gastric Banding:
- Pros: reversible, adjustable, minimal nutritional deficiencies
- Cons: lower weight loss, higher risk of complications
-
Sleeve Gastrectomy:
- Pros: high weight loss, minimal nutritional deficiencies
- Cons: irreversible, higher risk of complications
-
Biliopancreatic Diversion with Duodenal Switch:
- Pros: high weight loss, improvement in comorbidities
- Cons: high risk of malnutrition, vitamin deficiencies
Patient Selection
- Optimally suited patients: those with a BMI ≥40, or BMI ≥30 with comorbidities
- Contraception recommendations: Barrier, Nexplanon, Depo-Provera, IUD for 12-18 months
- NSAIDs avoidance: for life after bariatric surgery
Post-Bariatric Surgery Complications
- Early complications (less than 30 days): anastomotic leak, bleeding, infection
- Small bowel obstruction: most common 2-4 weeks post-operative
- Hypoglycemia: accelerated pouch emptying, excess GLP1 production, and excess insulin release
- Spitting up white foam: likely due to dumping syndrome
- Fluid intake: avoid drinking fluids 30 minutes prior/after eating after bariatric surgery
- Qualification for bariatric surgery: BMI ≥40, or BMI ≥30 with comorbidities
- Qualification exceptions: individuals with type 2 diabetes, BMI of 30-34.9, who do not achieve substantial weight loss or comorbidity improvement using nonsurgical methods
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