SURG - Bariatric Surgery.pdf

Bariatric Surgery 101 Jaime Lee Bull MPAP, PA-C, FASMBS-IH February 20, 2024 At the conclusion of this lecture and completion of required readings, the student will be able to: 1. Discuss the benefits and risks of bariatric surgery. Objective s 2. List selection and exclusion criteria for patients c...

Bariatric Surgery 101 Jaime Lee Bull MPAP, PA-C, FASMBS-IH February 20, 2024 At the conclusion of this lecture and completion of required readings, the student will be able to: 1. Discuss the benefits and risks of bariatric surgery. Objective s 2. List selection and exclusion criteria for patients considering bariatric surgery. 3. Compare and contrast the general technique, indications, contraindications, and potential complications of the following surgical interventions for weight loss: a. Laparoscopic sleeve gastrectomy b. Roux-en-Y gastric bypass c. Gastric banding d. Biliopancreatic diversion with duodenal switch (BPDDS) 4. Discuss patient monitoring and follow-up following bariatric surgery. 5. Counsel a patient on expectations and necessary lifestyle modifications following bariatric surgery. Benefits of bariatric surgery Significant improvement of metabolic disease/comorbidities - Significant improvement/ resolution insulin resistance - Decrease in overall morbidity and mortality rates - Preopera tive Evaluatio n Initial Visit with Bariatric Surgery MD/PA Diagnostic Screenings including but not limited to: Labs Sleep Apnea Evaluation/Sleep Study RUQUS Chest X-Ray EKG UGI/EGD Psychology/Mental Health Nutrition Evaluation Results Visit with MD/PA Cardiology/Pulmonology/Endocrinology/ Hematology Clearance PAT/Surgery Types of bariatric surgery Restrictive: Reduces stomach reservoir, limits amount of food consumed. No manipulation of small intestines. Malabsorptive: limits amount of nutrients absorbed by bypassing a portion of small intestines. - Adjustable Gastric Banding - Single Anastomosis Duodenal Switch - Sleeve Gastrectomy 9/3/20XX - Roux-en-Y Gastric Bypass - Biliopancreatic Diversion w/ Duodenal Switch Presentation Title 14 Sleeve Gastrecto my (SG) Sleeve Gastrectomy (SG) First performed 1990 as part of a 2 stage-procedure for Duodenal Switch and Performed as Single Procedure in 1999 Currently most performed bariatric surgery in the USA Surgery Steps: Mobilize the greater curve and fundus If present, repair hiatal hernia 75-80% stomach resected via surgical stapler- permanently removed from body Physiology of Weight Loss: eat less, less hunger hormones/stretch receptors by removing the fundus Pt can be discharged home day of surgery Relative Contraindications: Barrett’s Esophagus, Severe GERD, Achalasia Most Common Postoperative complications s/p Sleeve Bleeding/Infection Recurrent hiatal hernia Nausea/Vomiting/Dehydration Staple line leak Weight regain/not enough weight loss Sleeve dilation Anxiety/Depression Stenosis/strictures Disordered eating Worsening GERD/de novo GERD Potential need for revision or conversion to RYGBP Gastritis/Esophagitis Roux-en-y Gastric Bypass (RYGBP) Roux-en-y Gastric Bypass (RYGBP) First performed in 1960’s by Edward Mason, MD (Father of Bariatric Surgery) Currently 2nd most performed bariatric surgery in the USA Surgery Steps: Create a small proximal gastric pouch Divide jejunum in 2 sections: 75-150 cm Roux-limb (alimentary limb) attached to gastric pouch (gastrojejunostomy) and Biliopancreatic limb (biliary limb) that remains attached to “remnant stomach” and bile ducts Jejuno-Jejunal anastomosis: Biliopancreatic limb connected to distal end of Rouxlimb Mesenteric defect under JJ closed to prevent internal hernia (Peterson’s Defect) Physiology of Weight Loss: Restrictive & Malabsorptive Relative Contraindications: Drug/ETOH addiction, Hx of gastric ulcers, Crohn’s disease, uncontrolled gout Most Common Postoperative complications s/p RYGBp Bleeding/Infection Nausea/Vomiting/Dehydration Pouch dilation/Esophageal dilation Obstruction at GJ anastomosis/JJ anastomosis Anastomotic leaks Anastomotic stenosis/stricture Gastric ulcers/marginal ulcers Internal hernia Dumping Syndrome Anemia/Nutritional deficiencies/ Osteoporosis Protein malnutrition Gout exacerbation Weight regain/not enough weight loss Anxiety/Depression Disordered eating Need for Revision/Repair internal hernias Single anastomosis duodenal switch (SADI) Single anastomosis duodenal switch (SADI) First described by Torres in Spain (2007) Surgery Steps: Create sleeve gastrectomy over 40+ Fr bougie Identify ileo-cecal valve and count back 300 cm, tack loop of bowel to mesentery in RUQ Mobilize duodenum posteriorly to gastroduodenal artery; resect duodenum distal to pylorus Anastomosis between duodenum and ileum- creates a common channel of 300 cm to absorb nutrients Physiology of Weight Loss: Restrictive & Malabsorptive Relative Contraindications: Drug/ETOH addiction, Barrett’s, Crohn’s disease/ UC, AI disease Biliopancreatic Diversion w/ Duodenal Switch (BPD-DS) Biliopancreatic Diversion w/ Duodenal Switch (BPD-DS) First created in 1988 by Hess (USA), published by Marceau in 1993 (Canada) Surgery Steps: Create sleeve gastrectomy over 40+ Fr bougie Divide duodenum 2-3 cm distal to pylorus Alimentary limb divided 250 cm from ileo-cecal valve and connected to duodenum Ileo-ileal Anastomosis created 75-100 cm from ileo-cecal valve Mesentery closed to prevent internal hernia Physiology of Weight Loss: Restrictive & Malabsorptive Relative Contraindications: Drug/ETOH addiction, Barrett’s, Crohn’s disease/ UC, AI disease Most Common Postoperative complications s/p SADI/BPD-DS Bleeding/Infection Nausea/Vomiting/Dehydration Nutritional deficiencies- highest risk among bariatric procedures Sleeve dilation/Esophageal dilation Anemia Anastomotic leaks/stenosis/stricture Osteoporosis Anastomotic/marginal ulcers Protein malnutrition/Muscle Wasting Sleeve stenosis/strictures Gout exacerbation Small bowel obstruction- internal hernia/ Anxiety/Depression Disordered eating adhesions Need for Revision/Repair internal hernias Adjustable Gastric Banding (AGB) Presentation Title 9/3/20XX 26 Adjustable Gastric Banding (AGB) First introduced in 1993 Surgery Steps Band placed across upper stomach: 1 cm below esophago-gastric junction (creates a pouch) Secure band w/ 3-4 gastric sutures Fixation of port within subcutaneous fat vs suture to muscle fascia Physiology of Weight Loss: Restrictive Pt can be discharged home day of surgery Relative Contraindications: Severe GERD, Barrett’s Esophagus, Achalasia Most Common Postoperative complications s/p AGB Bleeding/Infection Nausea/Vomiting/Dehydration Weight regain/not enough weight loss Band Slip/Erosion Anxiety/Depression Port issues: flip/leak Disordered eating Pouch dilation/Esophageal dilation Need for Removal/Revision/ Conversion to another procedure Food bolus/Obstruction Revision/conversion to other Bariatric procedure Adjustable Band and Port Removal to Sleeve Sleeve to Gastric Bypass Gastric Bypass Distalization Sleeve to SADI/BPD-DS SADI to BPD-DS Other Bariatric/Weight Loss Procedures Endoscopic Balloons Endoscopic Sleeve Stoma Fix (Endoscopic Bypass Revision) Aspire Assist Percent Excess weight loss (EWL) s/p Surgery Calculate: (Initial weight – Post-op weight)/(Initial weight – Ideal weight) x 100 - SG (Sleeve gastrectomy) 55-70% EWL Long term – unknown 10-year studies are being finalized - RYGBP (Gastric bypass) 65-80% EWL Long term - 20% regain weight - BPD-Duodenal Switch/SADI (Duodenal Switch) 75-95% EWL Long term – unknown - AGB 35-40% EWL Postoperative concerns associated with surgery 9/3/20XX Presentation Title 33 Early complications s/p bariatric surgery ( 7 days: likely erosion/ulcer at anastomosis or staple line Wound Infection Pain, excessive drainage, fever/chills, leukocytosis If intra-abdominal infection/abscess may require IR drainage vs re-operation late complications s/p bariatric surgery (>30 Days) RYGBP: Gastro-Gastric Fistula Increased ingestion of food- passing through gastric remnant (digested and absorbed) Non-healing ulcer should raise concerns for fistula AGB: Band Erosion Possible Fever, pain, Leukocytosis Suspect if band full but no restriction or obstructive symptoms Dx w/ EGD and surgical consult for removal of band Incisional Hernia Internal Hernias- herniation through defect in mesentery Intermittent, post-prandial pain and emesis Suspect: Diagnostic Laparoscopy vs Sudden/Acute is a surgical emergency Early or late complications s/p bariatric surgery Small bowel obstruction- most common > 6 mos after surgery Pain, n/v, constipation/obstipation Possible association w/ internal hernia, narrowing of Roux limb associated with scarring, intussusception, adhesions Stricture- most common 4-6 weeks after RYGBP Post-prandial, epigastric abdominal pain/vomiting, +/-frothy emesis Possible association w/ narrowing of anastomosis or angulation of intestinal limbs Band Obstruction/Slip/Prolapse Gallbladder disease Marginal ulcers- most common at anastomotic site (NSAIDs, steroids, nicotine, ETOH) Abdominal pain, n/v NSAIDs, steroids, nicotine, ETOH PPI BID and Carafate QID Surgical Follow-up appointments after surgery 2-week post-op with MD/PA 2/3-month post-op with MD/PA 6-month post-op with MD/PA 9-month post-op with MD/PA 12-month post-op with MD/PA Annually on the anniversary of surgery date for life recommended Nutrition Principles after surgery Diet Progression: 2 weeks clear and full liquids, 1-week pureed texture. Day 21Week 8: fork tender/soft diets Nutrition post-op visit within first 2-3 weeks after surgery. Eat 3-5 small meals throughout the day. Meal should last 20-30 minutes. Chew food thoroughly. Do not drink fluids 30 mins prior/after eating. Avoid carbonation. Protein goals: 60-80 grams SG, RYGBP, ABG. 80-100 grams SADI/BPD-DS, RYGBP distalization/revision Bariatric Vitamins for life- depends on type of surgery Follow-up recommended: 3, 6, 12 months, annually after surgery Post-op Labs (AACE, TOS, ASMBS) 3-6 months, 12 months/annually: CBC, BMP, Hepatic Panel, Lipid Panel, Fe studies/ Ferritin, B12, Vit D, TSH, PTH, A1c BPD-DS/SADI: Add-on Vit A, K, E, Zinc, Copper, Ceruloplasmin Additional topics for patient counseling Avoid NSAIDS for life (Motrin, Ibuprofen, Aleve, BC, Goody’s) especially after RYGBP, SADI, BPD-DS If needs short course of NSAIDs, recommend PPI daily Long-term steroid use- avoid if possible If needs > than short course, recommend PPI daily Pregnancy- Barrier, Nexplanon, Depo-Provera, IUD recommended. OCP’s may not be as effective. Recommend avoiding for at least 12 months s/p Sleeve & RYGBP Recommend avoiding for at least 18 months s/p SADI, BPD-DS, Bypass Revisions Alcohol- recommend avoiding lifelong Tobacco/Vaping- recommend avoiding lifelong especially anastomotic procedures 9/3/20XX Presentation Title 41 Consequences of nutritional deficiencies Calcium/D: Osteoporosi s B12/B6: Peripheral neuropathies Protein/ Biotin/Zn: Hair thinning Iron/Folate/ B12: Anemia Folate: Birth defects Zn/Vit E: skin and hair abnormalitie s B1: Nausea/ Vomiting, Wernicke’s Encephalop Vit K: athy coagulopathi es Vit A: Night