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Bariatric Surgery - Coggle Diagram
Bariatric Surgery
Side effects
early satiety
reduce gut capacity
↓ ghrelin (unsure if sustained)
causes: the loss of reservoir function, denervation, disruption of the pyloric mechanism and the type of reconstruction
metabolic/nutritional alterations
B12 deficiency/pernicious anemia
cause
in gastric surgery, no IF → no IF absorption
tx: 3-minthly hydroxocobalamin injections
Blind Loop Syndrome → bacterial overgrowth in jejunum → malabs. of fat, B12, other B vit.
tx: broad spectrum antibiotics
complete cure may req. revisional surgery
vitB supp. pre+post tx
AKA stagnant loop syndrome. surgical complications, inflammatory bowel disease. scleroderma, jejunoileal diverticula
Vitamin B12 deficiency
Folate deficiency
Iron deficiency
Vitamin E deficiency
always seen in total gastrectomy, 50% of partial gastrectomy
May take sev. years to develop
dx: methyl-methionine testing > serum B12 in PPI use
R/O bacterial overgrowth, early satiety, dumping, relative pancreatic insufficiency
Fe deficiency anemia
40-45% pts post-partial-gastrectomy
causes: impaired intake
achlorhydria → ↓absorption. SI will adapt and take over absorption.
tx: 1st year post-op, consider Fe+vitC supp
gastric cancer risk ↑4x in remnant stomach.
dehydration, constipation
fluids 1.5–2 l/day
Re-education and occasional laxatives are advised
all sorts of pro/vit deficiencies
dumping syndrome
EARLY DUMPING
: hypertonic load to the small intestine triggering autonomic reflexes and release of vasoactive peptides
gut hormones involved: serotonin, vasoactive intestinal peptide (VIP), cholecystokinin (CCK), neurotensin, peptide YY, enteroglucagon
proximal small intestine with hypertonic food also leads to rapid movement of fluid into the gut from extracellular space resulting in diarrhoea
symptoms (~30min postprandial)
epigastric fullness (main in upper abdomen
sweating
faintness/palptations
quite common in the first weeks or months but improve over the months from small bowel adaptation or unconscious modification of diet
tx
education: eat small meals, restrict carbohydrate intake and avoid too much fluid
give reassurance
LATE DUMPING
: reactive hypoglycemia (2-3h postprandial)
rapid CHO absorption -> ↑↑ insulin → hypoglygemia, blackouts, seizures
v common; ~85% of bariatric pts
bile reflux gastritis
bilious vomiting
dx by upper GI endoscopy + Tech hIDA scanning
gastric emptying study r/o gastroparesis
tx: PPI, H2 blockers (rarely helpful)
revisional surgery
rare (1-2%, more in Billroth II than RNY)
GORD (gastro-oesophageal reflux dz)
more prevalent as ↑BMI
(effectiveness of antireflux procedure ↓ in obese pts
tx: RNY is most effective.
antireflux procedure (lap. Nissen fundoplication) > revsion surgery
gastroparesis
delayed gastric emptying in absence of mechanical obstruction
most common post-gastrectomy syndrome, esp with truncal vagotomy, inversely proportional to extent of gastric resection
tx
7-14d: time/prokinetic agents
corrective procedure, dep. on original procedure (often R-Y reconstruction and completion vagotomy)
dx
r/o metabolic (electrolyte, endocrine, meds). mechanical (stoma edema, small leaks, adhesions, kinking, hematoma, intussusception, stricture)
afferent/efferent loop syndromes
mechanical problem with partial obstruction of afferent limb (kinking, angulation, stenosis, adhesions)
efferent/Roux limb: primary recipient of food after surgery
afferent/hepatobiliary limb: anastomoses with biliary system, primary recipient of biliary secretions → anatomosis at mid jejunum
tx: always surgical.
Billroth II revision
Billroth II → Billroth I
Billroth II → RNY w/ long Roux limb + complete vacotomy
S/S
(common: Chronic type)- AFFERENT
severe postprandial pain, bile/pancreatic secretions build up in afferent limb → intraluminal pressure overcomes obstruction → projectile bilious vomiting w/ immediate relief of pain
Efferent: less common; difficult to distinguish from afferent loop syndrome/bile reflux gastritis.
adhesions/internal hernia behind gastrojejunal anastomosis
Roux syndrome
s/s: postprandial epigastric fullness, nausea, intermittent vomiting, wt loss
atonic roux limb → impede gastric emptying
loss of duodenal pacesetter potentials that would normally spread to terminal ileum
↓ when jejunum resected → ectopic pacemakers spread retrogradely to stomach
tx: trial of prokinetic agents
or aggressive gastric resection w/ RY construction
more common w/ large gastric remnant, after truncal vagotomy
diarrhea
causes
early dumping
bacterial overgrowth
↓ gastric acid + form blind loops → accumulate microbiota in colon
→ destroy brush border, consume B vit
deconjugate bile acids → fat malabsorp → steatorrhea, wt loss
vagotomy: vagus nerve is cut
↓intestinal motility → ↑↑emptying of liquids, ↓acid, ↓bile acid absorp., bacterial overgrowth in proximal bowel
severe form can be 10-20 episodes/d, explosive, indep. of food intake
malnutrition, wt loss, weakness
testing: glycholate breath test
tx:
bacterial: antibiotics (metronidazole/neomycin)
probiotics (fresh unpasteurized yogurt)
relative pancreatic insufficiency: pancreatic enzyme supp (creon)
vagal denervation
diet modif
bile chelator (cholestyramine)
oral neomycin (antodiarrheal agents)
SEVERE: surgical intervention
surgical complications
usual complications of gastrointestinal surgical procedures and are managed similarly
(haemorrhage, anastomotic leak, and anastomotic strictures)
complications general to any abdominal operation (pneumonia, deep vein thrombosis, urinary retention and ileus)
Small bowel motility returns within a few hours and gastric and colonic motility after a few days, depending on the degree of surgical trauma [7], [8], [9
gastritis
band erosion
leakage from surgical incision
vomiting
stomach ulcers
tx
diet progression!
1-2d NPO
2-3d clear liq (<1/2c)
semisolids/puree (4-5d ~ 4wk)
1/2 -> gradual incr to <1c
soft foods, 5wk up to 8wk
3/4~1c 2x/d
regular SFM + snacks >6wk
avoid popcorn, nuts, meats w/ gristle, dried fruits, stringy/coarse f/v, soda, bread, seeds, granola
protein is priority (80-100g/d)
1000-1200kcal
supp
fat-soluble vitamins (ADEK)
vit D (800-1000IU d)
bone heath. high deficiency rate in OB indiv. prior to surgery (60%)
Ca 1000-2000mg/d; divided into doses
deficiency postop v common (50%)
Ca citrate absorb better than Ca Carbonate
B complex
vit B12: 1000mcg /wk
1/3 pts develop deficiency
thiamin: critical for cho metab. caused by nausea, vomitting, en restriction, ETOH intake
b1 (thiamin)
fe (325mg ferrous/65g elemental)
↓ meat intake → ↓ fe intake
↓ HCL
take w/ vitC, NOT with Ca supp
MVI
folate
Cu
Zn
Monitoring
physical assessment:
poor intake
muscle mass loss
fluid accumulation
grip strength
subcutaneous fat loss
*How different btwn gastroduodectomy VS gastrojejunectomy?
counseling
initiate/continue LT wt mngmt behaviors (food choice, PA, etc.)
tailor to indiv lifestage/circumstances; acknowledge previous responses to transitions/stressors
adequate hydration
avoid adverse effects (dumping, vomiting)
Restrictive only
gastroplasty
suture stomach smaller
vertical band
1) staples to partition the stomach
2) create small gastric pouch (only small opening to distal stomach
gastric band
reduce stomach size to 10-15ml capacity; band can be adjusted to make bigger/smaller (via saline injection)
sleeve
(Laparoscopic sleeve gastrectomy)
cut away antrum of stomach from pylorus (sleeve) + form pouch around a bougie on lesser curvature of stomach (reduce stomach capacity by remove fundus + body
balloon
Not malabsorptive = not as much wt loss
restrictive + malabsorptive
Roux en Y
create small pouch (staple) → early satiety
bypass stomach + upper SI → malabsorp.
stomach remnant no longer receives food but remains secretory
gold standard!
biliopancreatic diversion
DPS w/o duodenal switch
1.1% 30-day mortality, 70-80% wt loss over 2yrs
distal gastrectomy anastomosed to ileum
anastomosis btwn biliopancreatic limb + alimentary (food-containing) limb @ terminal ileum
preserve pylorus, so dumping syndrome + anastomotic ulcers less likely
w/
duodenal switch
DBS + sleeve gastrectomy + longer common limb
vertical sleeve gastrectomy, duodenum divided 4cm distal to pylorus
small bowel divided @ midpt, distal small bowel (alimentary) anastomosd to duodenum.
ilio-pancreatic limb(proximal) anastomosed to ileum.
mildly restrictive, mainly malabsorptive.
75-80% excess wt loss in 2yr
excision of fundus -> ↓ ghrelin, ↓ appetite
SIGNIFICANT MALABS. bc only leaves 1m of common smal bowel. ↑ wt loss, but ↑risk pro/vit deficiency
SADI Single anastomosis duodeno-ileoal bypass w/ sleeve gastrectomy
simplification of duodenal switch; serves as bileopancreatic diversion but easier to perform
anastom. btwn duod/small bowel, common limb = 3M. incr bowel frequency
excess weight loss 5 years after SADI procedure remains comparable to the DS at 90% (compared with 50–70% for the sleeve or bypass
MGBP (
omega loop mini gastric mypass
)
gastrojejunal anatomosis btwn long gastric pouch + jejunal omega loop
promoted as quick/effective alternative to RYGB, but controversial
only 1 anastomosis so in theory fewer complications, but risk of biliary reflux + anastomotic ulcers w/ dysplastic changes of gastric/esophageal mucosa
req
morbid OB (BMI>40)
OB (BMI>35)+comorbidity (T2DM, HTN
all non-surgical measures unsuccessful
partial gastrectomy
(originally used for peptic ulcers)
gastrojejunostomy (Billroth II)
gastroduodenostomy (Billroth I)
Outcomes
most patients have successful wt loss (50% of excess BW) in 2 yrs
regain in ~50% after 2 years
complications as high as 40%
gastrectomy is (surgery) removal or partial removal of the stomach while gastrostomy is (surgery) the surgical procedure for making an opening in the stomach as part of an operation
