• Restrictive Surgery * Adjustable gastric banding * Vertical banded gastroplasty * Vertical sleeve gastrectomy

• Malabsorptive procedures * Roux-en-Y gastric Bypass

Restrictive Procedures

• Restricts the amount of food the stomach can hold

• Does not interfere with normal digestion

The pouch holds about 1 ounce of food that later expands to 2 - 3 ounces

Adjustable Gastric Banding

A hollow band is placed around the stomach near its upper end, creatinga small pouch and a narrow passage into the larger remainder of the stomach

Vertical Banded GastroplastyIn this procedure,both a band and staples are used to create a small pouch

A vertical pouch is created by stapling the back wall of the stomach at the esophagogastric junction. The end of the pouch is constricted with a band or ring

Vertical Sleeve Gastrectomy

In this procedure, the stomach is divided vertically and stapled removing more than 85% of the stomach. The remaining stomach is shaped like a slim banana and measures 1-5 ounces.

This part of the procedure isnot reversible. This surgerycan be stage 1 of a 2 stagedRoux-en-Y

Malabsorptive Procedures

• Combines stomach restriction with partial bypass of the small intestine

• Reduces the amount of calories and nutrients the body absorbs

• Produces more weight loss than restrictive operations

Roux-en-Y Gastric Bypass1. A small pouch is created to restrict food intake

2. A Y shaped section of the small intestine is attached to the pouch to allow food to bypass the lower stomach, the duodenum, and the first portion of the jejunum.

So who gets these surgeries….• BMI >40kg/m2 without medical complications• BMI >35kg/m2 if a severe obesity related medical problem is present

- Sleep apnea- Hypertension- Type 2 Diabetes- Heart failure

Calculating BMI:

Wt in lbs x 704.5 / height in inches height in inches

But its not that simple. There are risks

Early Complications• Pulmonary Embolism 0 - 3.3%• Anastomotic Leaks 2 - 3%• Bleeding 0.6 - 4%• Wound Infections Open 10 -15% Laproscopic 3 - 4%• Small bowel obstruction 1 - 2%

Later Complications• Dumping Syndrome 50% after RYGB• Marginal ulcers 3 - 10%• Vitamin deficiencies many have this pre-op

Pulmonary Embolism

The lodging of a blood clot(embolus) in one of the arteries of the pulmonarycirculation

Cause: underlying deep vein thrombosis breaks off and travels via the vena cava

Risk factors for DVT / PE

Venous stasis– Prolonged immobility– Vascular Injury

Hypercoagulability– Cancer– Use of BCP– MI / A fib– COPD– Obesity

Clinical Features of PE History

– Chest pain: usually pleuritic– Dyspnea– Apprehension– Cough, hemoptysis– Syncope

Physical– Tachypnea (RR> 16/min)– Wheeze, rhonchi, rub– Temperature >100– Tachycardia >100

DVT / PE Prevention• Sequential Compression Devices at all times unless ambulating

• SQ Heparin•

• Lovenox if poor mobility, hx DVT or BMI>60

• Out of bed Day of Surgery and Out of Bed 3 times a day each day after that

Treatment for PE Oxygen therapy Cardiac Monitoring Pain Control Thrombolytic

therapy– TPA

Monitor of clotting factors Once stable, may need filter placed

to prevent further clots from traveling

Anastomotic LeaksSymptoms:• Anxiety• Shoulder or back pain• Persistent unexplained tachycardia• Progressive tachypnea• Altered urination & bowel frequency

Fever and abdominal tenderness may be absent!

Suspicion of leak: radiographic GI contrast study

If patient is rapidly deteriorating and Pulmonary Embolism ruled out: this patient might need to go for exploratory surgery

BleedingPotential causes:• Marginal ulcers (higher incidence in smokers)

• Ulcers in the bypassed stomach or duodenum• Gastritis• Bleeding from fresh staple lines

Symptoms• Blood in emesis or stool• Lowering HCT/HCB• Symptoms depend on the severity of the bleed

Treatment • Sucralfate: gastric acid suppression• If persistent, endoscopy to identify site of bleeding

Infection Risk higher with open cases vs laparoscopic

Symptoms• Fever• Elevated white count• Redness, warmth, swelling, drainage at incision site

Treatment• Antibiotics • Primary Dressing left on til Day 2 then open to air• Use splint pillows to prevent tension on incision line

Prevention: aseptic technique

Small Bowel Obstruction( can occur post-operatively or months after surgery)

Symptoms Post prandial abdominal pain Nausea Vomiting (may not be prominent symptom)

Diagnosis: * radiographic confirmation by CT Scan, UGI

Treatment Depends on the etiology of the obstruction ie. adhesions, hernias but may required laparoscopic exploration

Marginal UlcersIncidence: 5% of patients (higher in smokers)

Etiology: chronic exposure to gastrojejunal anastomosis to acid or NSAIDS

Diagnosis: endoscopy

Treatment: gastric acid suppression Sucralfate (successful in 95%)

* Surgical treatment if persistent pain, or recurrent bleeding

Cholelithiasis• Incidence: 38% of patients within 6 months of surgery

• Etiology: very low-calorie diets (like you have after gastric bypass) don't contain enough fat to cause the gall bladder to contract and empty it's bile. If the gallbladder doesn't contract enough to empty it's bile, gallstones can form.

• Prevention: Ursodiol 300mg po BID x 6 months Concommitant cholecystectomy

Dumping SyndromeIncidence: 50% of patients after RYGB

Symptoms: nausea, shaking, diaphoresis, and diarrhea shortly after eating high quantities of refined sugar or fat

Treatment: Avoid foods that provoke symptoms

Effects: generally subsides in 12 to 18 months after surgery

Vitamin B12 DeficiencySymptoms:

• Megaloblastic anemia

• Pancytopenia (leukopenia, thrombocytopenia)

• Paresthesias• Peripheral Neuropathy• Demyelination of dorsal column and corticospinal tract

• Irritability, personality change• Mild memory• Depression• Psychosis

• Increased risk of myocardial infarction and stroke

Prevention: Vitamin B12 1000mg IM Qmonth for life Vitamin B12 1000-2000mg SL daily

Folic Acid DeficiencyIncidence: As high as 35% as folate is absorbed in the small intestine

Symptoms: Megaloblstic anemia, periperhal neuropathy thrombocytopenia, glossitis

Prevention: Folic acid 1mg po daily

Vitamin B1 / Thiamine Deficiency

Beriberi Disease: affects the peripheral nervous system

Symptoms: weakness, ataxia, numbness, nystagmus, difficulty walking Treatment: Thiamine 100mg IV daily x 7days

Wernicke’s Encephalopathy: affects the central nervous system

Symptoms: mental confusion, memory loss, progressive paralysis, coma, death Treatment: Thiamine 100mg IV Q8hrs until symptoms resolve

Zinc Deficiency

Symptoms:

• poor wound healing, • hair loss, • nausea, • impaired smell, • impaired taste

Supplements: Zinc 15mg po daily

Follow-up monitoring is key!

   X Vitamin K

   X Uric acid

   X Lipid panel

XX X Bone density

XX X Folate

X X XParathyroid hormone

XX X Other fat-solublevitamins

XXXX Vitamin D

XXXXXVitamin B12

XX XXAlbumin

XXXXXMagnesium

XXXXXIron studies

XXXXXChemistry panel

XXXXXComplete blood count

Annual24

Months18

Months12

Months6

MonthsTest

Psychological effects• Grieve the loss of food

• Increase in self esteem, self confidence, assertiveness and expressiveness

• Changes in social circles

• Difficulty with social and business functions that revolve around food

• Resentment to suddenly improved social acceptance

• Desire for cosmetic changes to deal with excess skin

Bariatric Surgery Test

1. Restrictive surgeries restrict what a. your appetite b. your stomach size c. your intestines d. your body’s ability to break down food

2. Which of the following symptoms may not be present in a patient with an anastomic leak

a. Persistent unexplained tachycardia b. Shoulder or back pain c. Progressive tachypnea d. Fever

3. What is the incidence of Cholelithiasis after bariatric surgery?

a. 38% b. 18% c. 8% d. 2%

4. All of the following deficiencies must be monitored for in a bariatric surgery patient EXCEPT

a. Vitamin K b. Vitamin B1 c. Vitamin B12 d. Vitamin C

5. What is the most important nursing intervention to prevent a DVT/PE in bariatric surgery patients

a. Assist with mobility at least 3 times a day b. Limit mobility for the first post-op week c. Provide a splint pillow d. Limit fluids