Q: 25 - 26

Q25: Rx Complic Bariatric Surg

Surgical eligibility: BMI > 40 or BMI > 35 + comorbidities.

Operative mortality ~ 1%

Ischemia leak Signs – Increased RR, HR, WBC, pain, fever.

Marginal ulcers develop in upto 10%, Tx- PPI

Stenosis – serial dilation

Obstruction --

Rx Complic Bariatric Surg

Dumping Syndrome – post gastrectomy, vagotomy w/ pyloroplasty.

Due to rapid entrance of carbohydrates into the small bowel.

90% resolve w/ medical therapy

Two phases: 1) Hyperosmotic load – fluid shift, 2) Reactive increased insuline release, decreased blood Glucose.

Tx – medical – small meals, low fat, low carbohydrates, no liquids w/ meals, no laying down,

Rx Complic Bariatric Surg

Surgical options: Conversion of Billroth I or II ro Roux-en-y gastrojejunostomy.

Increase gastric reservoir using a jejunal pouc or increase emptying time with a reversed jejunal loop.

Roux stasis – stasis of chyme in Roux limb due to loss of jejunal motility. Tx- prokinetics, metoclopromide, Sx – shorten the Roux limb to 40cm

Rx Complic Bariatric Surg

Chronic gastritis atony --- Delayed gastric emptying, nausea, emesis, pain, early satiety. Tx – Prokinetics, metoclopromide Sx – Near total gastrectomy w/ Roux-en-Y

Alkaline Reflux gastritis Postprandial epigastric pain assoc. w/ N/V. Not

relived w/ emesis. Reflux of bile into stomach Tx – H2 blockers, metoclopromide, cholestyramine Sx– conversion of B-I or B-II to Roux-en-Y

gastrojejunostomy w/ afferent limb 60cm distal to gastrojejunostomy.

Rx Complic Bariatric Surg

Blind loop syndrome W/ B-II or Roux-en-Y Pain, diarrhea, malabsorption, B12 deficiency,

steatorrhea due to bacterial deconjugation of bile GNR, E. coli overgrowth of bacterial and stasis in

afferent limb. Tx – Tetracyclines, Flagyls, Metoclopromide. Sx– Reanastomosis with shorter 40cm afferent

limb.

Q26: Rx Duodenal Fist / Crohn’s dis

Medical Tx – Infliximab, TNF-alpha inhibitor for fistula

TPN.

Most upto 90% will eventually need resection.