- Candidates
- BMI >35kg/m2 with comorbidity or body weight >80lbs above ideal body weight with co-morbidity
- Co-morbidities: Htn, cardiovascular dysfunction, hlp, DM II, respiratory insufficiency, stress incontinence, gerd, carcinomas
- BMI >40 or body weight >100lb above ideal body weight
- Mortality 3x normal weight parallel
- Considering BMI 30 with diabetes
- BMI >35kg/m2 with comorbidity or body weight >80lbs above ideal body weight with co-morbidity
- Procedures: Restrictive, malabsorpitive, or a combination
- Sleeve gastrectomy: ~40 fr bougie
- Works by restriction and by rapid transit causing satiety
- 75% resection of stomach: no bypass
- Greater curvature of stomach is devascularized prior to resection
- 60%excess wt loss at 3 years
- Complications
- Gastric Leak: most frequent complication 0.9%
- Stricture, bleeding, PE, delayed gastric emptying, abscess, ssi, splenic injury trocar hernia
- Revision rates 4%
- Adjustable gastric banding
- Silicone band around proximal stomach: dissection through fatty tissue posterior to GE Jxn and creation of a tunnel for the band
- Pars Flaccida technique: reduces slippage to < 3%
- Small proximal pouch
- Fill band with fluid after 6wks
- Outpt procedure but more f/u needed
- Gradual lower weight loss: steady weight loss
- A/e
- Complication rate <1%, mortality < 0.1%
- 30% long term reop
- 20% failure rate
- Slippage: obstruction, vomiting, epigastric pain
- Can necrose fundus
- Dilation of esophagus: >5cm need to empty band
- Follow pt with barium swallow
- Erosion: avoid nsaids
- Perforation: often missed/late presentation
- Complication rate <1%, mortality < 0.1%
- Silicone band around proximal stomach: dissection through fatty tissue posterior to GE Jxn and creation of a tunnel for the band
- RYGB: Gastric Bypass
- Restrictive and malabsorptive
- 60ml proximal gastric pouch anastomosed to Roux limb, created 150cm from the ligament of treitz
- Rou-ex-Y limb anastomosed to stomach pouch
- 75-150cm alimentary limb
- 50-100cm afferent limb
- 10-15mm stoma not reinforced
- No fundus included in pouch: important for outcomes (hormonal)
- Hormonal changes in ghrelin, glucagon-like peptide-1, and peptide YY that influence eating behaviors and body weight.
- Reduced bile and lipolytic enzyme secretion 2’ no duodenal activation
- Delayed fat breakdown and micelle formation limits absorption. Can cx steatorrhea
- Advantage
- Mean EWL excess wt loss 60% at 12 mo
- 80% at 24 mo
- 75% at 30 months
- Low failure rate
- A/E
- Operative 30 d mortality 0.1-0.5%
- MC complication: dehydration
- Malabsorption: difficult to reverse
- Protein intolerance
- Divalent cations: (absorbed in duodenum): iron calcium magnesium
- Oral FeSO4 supplements decreases absorption of Ca, Mg, Zn
- b12 (stomach antrum-intrinsic factor)
- Supplementation necessary: Vit B, Ca, Vit D, Folate, Thiamine
- Vit B deficiency: occurs > 1 year after operation
- Macrocytic anemia and neuropathy
- Vit D deficiency: fat sol vit: Loss of fat absorption dec vit d, higher bone turnover and dec bone mass
- Follow pth, vit d, and ca levels
- High PTH means low ca or vit d
- Supplement with ergocalciferol
- Leak 1-2%, revision 4-8%
- Complications 2-5%
- Death 0.5-1%
- Biliopancreatic diversion
- Greatest weight loss and most nutritional problems
- 75% of stomach resected and bypass all but 250cm of small bowel
- Procedure
- Sleeve gastrectomy: 60Fr bougie
- Duodenum is divided 2 cm distal to the pylorus, preserving the blood supply and vagal innervation of the antrum.
- A Roux limb is created by dividing the small intestine 250 cm proximal to the ileocecal valve and anastomosing this to the postpyloric duodenal cuff.
- The bypassed biliopancreatic limb is sewn to the Roux limb 100 cm proximal to the ileocecal valve, creating the “common channel.”
- Vs RYGB
- More technically challenging
- Large gastric capacity
- less dumping syndrome
- more effective in reversing DM, HLP, HTN in super obese bmi>50
- >wt loss at 3 years in super obese
- Not strictly malabsorptive
- Hormone changes: specifically gastric bypass and sleeve gastrectomy
- Induce satiety: L cells of lower gut: Increases in GLP-1 and PYY
- GLP-1 released hindgut in increased amounts potent release of beta cell insulin release
- Decrease in Ghrelin: proximal stomach and fundus
- Normally: Arexogenic: induces hunger
- Proximal small bowel will make up for some of the ghrelin
- Mean excess weight loss after BPD > 70% in published series.
- 30d operative mortality 0.5-1.1%
- Jejunoileal bypass: not done
- a/e bypass segment bacterial overgrowth and protein malabsorption leads to cirrhosis
- Outcomes
- Resolution of co-morbidities
- DM 76% resolved
- 2’ to calorie restriction (some part form glp-1)
- Rapid wt loss 1lb/d.
- Improved sensitivity to insulin
- HLP 70% improved
- Htn 61% resolve
- Sleep apnea 85% resolved
- Operative mortality <30d:
- restrictive 0.1%
- bypass 0.5%
- biliopancreatic diversion 1.1%
- General Rules
- Postop: Can never smoke or take NSAIDS
- Not normal to vomit after gastric bypass
- Don’t give dextrose, give ns and thiamine
- Early Complications
- Pulmonary: apneic arrest, dvt/pe
- Apneic Arrest- anesthetic in fat
- Hypoventilation leading to resp/cardiac arrest
- Incidence <2%
- Prevention is key
- Pre-op sleep apnea dx
- Peri-op cpap: extremely important
- Admit high risk pt to monitored setting
- Limit narcotics
- Signs: desat, somnolence, mental status changes
- Tx: intubation
- Dvt/pe
- Incidence 1-2%, fatal pe 0.2%
- Risk factor: obesity hypoventilation syndrome
- BMI >55, male, lower extremity venous ulcer dz
- No longer consider prophylactic insertion of filter
- Tx: Heparin, ambulation, scds
- Symptoms: diaphoresis tachycardia hyopxia
- Enteric leaks
- Incidence: 1-8% higher with revision
- Possible locations
- gastroJ
- gastric pouch staple lines
- remnant gastric staple line
- J-Jostomy: typically high volume
- Pt deteriorates rapidly
- Technical issues
- Missed perf: blind instrument insertion
- Avoid devascularlizing the pouch/roux limb
- Avoid tension
- Ante colic: make a large groove in omentum
- Retrocolic less tension
- Consider longer pouch in super-morbidly obese
- Test anastomosis
- Presentation: not with peritonitis, can be insidious
- Tachycardia: HR >120 (most sensitive)
- Tachypnea, respiratory distress, hypoxia
- Elevated wbc
- Fever >101.5
- Sever abdominal pain
- Oliguria
- Mental status changes
- Dx
- UGI series: routine use debatable, doesn’t evaluate anastomosis of gastric remnant or distal
- CT
- Exlap
- Tx
- Leak control and drainage
- Supportive care
- Iv ABx
- Vent support-early trach
- Beware decubiti
- Nutrition: gtube preferred
- Remnant decompression/enteral feeding
- TPN
- Small bowel obstruction
- Early dx and or exploration to prevent acute gastric REMNANT distention
- Hemorrhage
- Early: intraluminal: staple line bleed: 50-70% stop spontaneously
- Tx IVF and blood product resuscitation
- a/e intraluminal blood can cause SBO: hemobezoar
- Late
- Peptic ulcer dz: bleeding ulcer in remnant
- Marginal ulcers: 2’ to smoking or nsaid use
- Dumping syndrome: post RYGBP: up to 70%
- Early: 15 min pc: d/t sudden osmotic load in jejunum
- isotonic fluid from plasma enters lumen: falls in BP
- stimulation of argentaffin cells: release of 5HT: serotonin sy
- Late phase: 1.5-3hr pc: hypoglycemia
- High glycemic index food is rapidly absorbed:insulin spike: glucose and K shift intracellular
- Tx: frequent dry meals, low carb, high protein, fluids between meals only
- Reinforces correct eating behavior
- Rhabdomyolysis
- 2’ muscle compression during surgery (concern >4hrs)
- Labs: Hyperkalemia, hypocalcemia, hyperphosphatemia, hyperuricemia, acidosis, aki, dic, compartment syndrome
- Cpk >5x nml, peaks 4-7 d. remains elevated 12 days
- Urine myoglobin
- Sx: pain, tenderness, swelling, bruising weakness
- Dark uring, fever, malaise, confusion
- Imaging: hyperechoic skeletal muscle on U/s
- CT: muscle necrosis/ calcification
- MRI: muscle edema
- Tx
- IVF: > 1.5 ml/kg/hr
- Mannitol
- Sodium bicarb pos: can accelerate ca/po4 deposits in tissues
- Don’t correct hypocalcemia
- Control hyperkalemia
- HD if necessary
- Wound infections
- Adipocyte hypertrophy changes adipose structure and impaires function
- Inflammatory mediators invade: chronic low grade inflammatory environment with angiogenic inhibitors and fibrosis, tissue becomes hypoxic
- Impaired collagen synthesis
- Early dx and or exploration to prevent acute gastric REMNANT distention
- Pulmonary: apneic arrest, dvt/pe
- Late complication
- Anastomotic strictures: within 6 weeks 10% incidence
- Lower with linear staples
- Controlled with balloon dilation
- Marginal ulcers ~6%
- Epigastric pain, can bleed/perforate
- Most tx with PPI: may need lifelong
- If unresolved: r/o gg fistula
- Nutritional:
- MC: B12, folate, vit d, calcium, iron, B1, B6, vit A, zinc, selenium, mg, Cu
- wernicke’s polyneuropathy (acute thiamine deficiency and glucose immediately), malnutrition
- Cholelithiasis
- MC during rapid wt loss >1.5kg or % BW /wk
- Cholesterol supersaturation of bile
- Increased nucleation
- Decreased calori intake lowers CCK secretion
- Obesity related cck resistance
- Concurrent routine chole controversial: 36% will get stones post RYGB
- Urso 300mg bid x 6 mo: prevents GS formation
- Weight regain
- 2’ pouch dilation or GG fistula
- MC 2’ to non complicance and poor food choices/portioning
- SBO: 0.5% incidence
- Etiology: internal hernias, adhesions, trocar hernias, JJ intussusception, hemobezoar
- Internal hernias can occur at the jejunojejunostomy defect, Peterson’s space behind the roux limb, or transverse mesocolon defect if retrocolic limb
- Sx: vague, pain out of proportion. Likely will not have vomiting
- Gastric remnant blow out is fatal: rapid dx and tx vital
- CT: can miss/be misread >60% of cases
- Low threshold for exploration
- Anastomotic strictures: within 6 weeks 10% incidence
- NB
- Unemancipated minors can’t consent (technically), need to assent with parental consent
- Medical tx
- Orlistat: antiobesity medication: inhibits gastrointestinal lipases and leads to dec fat absorption
- Sibutramine: oral agent inhibits neurotransmitter reuptake
- a/e cardiac morbidity
Bariatrics
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