bariatric surgery mr peter o’leary. history greek baros = weight iatros = physician kremen &...
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Bariatric Surgery
Mr Peter O’Leary
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History
Greek Baros = weight Iatros = physician
Kremen & Linner 1954 Jejuno-ileal Bypass
Mason 1967 Gastric Bypass Failure to gain weight post partial
gastrectomy for peptic ulcer disease
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Recognised as a general surgical sub-speciality by American College of Surgeons American Medical Association
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Mrs. KG (48) Referred by Orthopaedics re Gastric bypass for:
Weight reduction prior to hip replacement (OA)Improvement of mobilitySeeking procedure for 4 year
Current status Weight 135kg
Height1.75m
BMI 47
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HxPC
>9st until mid 20s
Gained weight since the birth of her children
Weight reduction measuresWeight watchersDieticiansAppetite suppressantsAll effective short term
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MedHx Osteoarthritis B/L hip Hypertension Hypercholestrolaemia Sleep apnoea Reflux and heart burn
NIDDM
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Family Hx Nil of note
Drug Hx NKDA Metformin Atenolol
SHx Non-smoker No alcholo Shop assistant
RoS Nil of note
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On Examination
Looked well but obese
Vitals normal
MSS Fixed flexion R knee
Joint line tender medially
Crepitus +
CVS, RS, Neuro - NAD
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Pre-op Advice
Advised about Procedure
Possible complication Post-op recovery
Endocrine assessment No pre-op consultation with Dietician No pre-op psychological evaluation
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Indications BMI > 40 (> 35 with co-morbid conditions)
sleep apnea cardiomyopathy diabetes mellitus musculoskeletal body size severely impacting on function
No medical or anaesthetic contraindications
No previous major upper abdominal surgery
No active drug or alcohol addiction history
No major psychiatric history
Well informed, motivated, and acceptable operative risks
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Pre-op Considerations Endocrinologist
Pituitary Thyroid Adrenal
Dietician Eating behaviour modification Post op diet adjustment, vitamin and
mineral supplementation
Psychological evaluation Psychiatric co-morbidities Change in relationship with food Behaviour modification techniques
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Please help…!
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
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Bariatric surgery
weight reduction surgery for morbidly obese1.BMI >40 (basically, >100 pounds above ideal
body weight).
2.BMI >35 with a medical problem related to morbid obesity.
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Surgical options
Stapling off of small gastric pouch (restrictive) roux-en-Y limb to gastric pouch
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
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Mechanism of gastric by pass
1. Creates a small gastric reservoir
2. Causes dumping symptoms when a patient eats too much food or high calorie foods, the food is dumped into the roux-en-Y limb
3. Bypass of small bowel by roux-en-Y limb
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
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Dose gastric by pass work?
Weight loss 50% of excess weight QuickTime™ and a
TIFF (Uncompressed) decompressorare needed to see this picture.
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Postop Complications Early (1 to 6 weeks)
Postoperative bleeding Anastomosis leak Bowel perforation Bowel obstruction Wound infections
Intermediate (7 to 12 weeks) Prolonged vomiting
Dietary indiscretions Bulimia Stricture at gastrojejunal anastomosis (4.6%)
Marginal ulcer Dumping syndrome (50% after roux en y)
Late (13 weeks to 12 months) Cholelithiasis Small bowel obstruction (adhesions) Secondary hyperparathyroidism
Leak after gastric
bypass on upper gastrointestinal series
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Long term eating habits Initially, the stomach tolerates 30 cc at one time 3 months, patients are ingesting ~1000 kcal in three to six
meals per day Dietary advice important at this stage
Six months, should be on 3 meals a day Food aversions develop esp if prolonged vomiting associated
with eating Such patients often express "buyers remorse" and may request
extensive investigations for problems with the gastric pouch Eating habits change compared to preoperative eating habits
Fresh fruits and vegetables are tolerated without a problem Some patients have continuing food intolerances, especially to red
meat, and become vegetarian
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Changes post surgery Weight loss
Rapid in the first six months Averages 4 to 7 Kg per month
Slows 2 to 3 Kg after 6 months Total weight loss peaks at 12 months Weight regain 18-24 months post op
Nutritional Deficiencies Inadequate intake of nutrients Alterations in the digestive anatomy
lack of intrinsic factor – B12 def Lack of acid in new pouch (R en Y) – Poor absorption of iron Ca and Vit D absorption decreased after surgery – Secondary Hyperthyroidism Thiamine def due to recurrent vomiting Little evidence available on the amount of supplementation required
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Cosmetic After 12 months, patients seek info about plastic surgery to remove abdominal
pannus Insurance companies will not cover it - cosmetic Exception if abdominal pannus becomes infected or excoriated Case series suggested that delaying panniculectomy until after weight loss is safer
and more effective
Physical function Fatigue improves, increased energy Exercise habits improve
increase in activities of daily living and recreational activities Musculoskeletal and back pain improves or resolves in the majority of patients Osteoarthritis improves to a lesser degree
Dependent on the degree of underlying bone and cartilage damage Sleep apnea improves
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Psychological Lethargy, depression, and other psychopathology Food used for emotional reasons, pre-op Grieve the loss of food Several studies have shown increases in self-esteem, self-
confidence, assertiveness, and expressiveness Improvements seen in social interaction, sexual activity, and
work performance
Pregnancy Greater fertility with weight loss Surgery not associated with adverse perinatal outcomes Pregnancy complications eg gestational diabetes, hypertension, and
macrosomia Period of rapid weight loss Gastric band may need to be adjusted nutritional deficiencies
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"un poco con la cabeza de Maradona y otro poco con la mano de Dios"