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Restrictive Surgery * Adjustable gastric banding * Vertical banded gastroplasty * Vertical sleeve gastrectomy Malabsorptive procedures * Roux-en-Y gastric.

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Presentation on theme: "Restrictive Surgery * Adjustable gastric banding * Vertical banded gastroplasty * Vertical sleeve gastrectomy Malabsorptive procedures * Roux-en-Y gastric."— Presentation transcript:

1 Restrictive Surgery * Adjustable gastric banding * Vertical banded gastroplasty * Vertical sleeve gastrectomy Malabsorptive procedures * Roux-en-Y gastric Bypass

2 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 ounces

3 Adjustable Gastric Banding A hollow band is placed around the stomach near its upper end, creating a small pouch and a narrow passage into the larger remainder of the stomach

4 Vertical Banded Gastroplasty In 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

5 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 is not reversible. This surgery can be stage 1 of a 2 staged Roux-en-Y

6 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

7 Roux-en-Y Gastric Bypass 1. 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.

8 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 / height in inches height in inches

9 But its not that simple. There are risks Early Complications Pulmonary Embolism % Anastomotic Leaks 2 - 3% Bleeding % Wound Infections Open10 -15% Laproscopic 3 - 4% Small bowel obstruction 1 - 2% Later Complications Dumping Syndrome 50% after RYGB Marginal ulcers % Vitamin deficiencies many have this pre-op

10 Pulmonary Embolism The lodging of a blood clot(embolus) in one of the arteries of the pulmonary circulation Cause: underlying deep vein thrombosis breaks off and travels via the vena cava

11 Risk factors for DVT / PE n Venous stasis –Prolonged immobility –Vascular Injury n Hypercoagulability –Cancer –Use of BCP –MI / A fib –COPD –Obesity

12 Clinical Features of PE n History –Chest pain: usually pleuritic –Dyspnea –Apprehension –Cough, hemoptysis –Syncope n Physical –Tachypnea (RR> 16/min) –Wheeze, rhonchi, rub –Temperature >100 –Tachycardia >100

13 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

14 Treatment for PE n Oxygen therapy n Cardiac Monitoring n Pain Control n Thrombolytic therapy –TPA n Monitor of clotting factors n Once stable, may need filter placed to prevent further clots from traveling

15 Anastomotic Leaks Symptoms: 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

16 Bleeding Potential 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

17 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

18 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

19 Marginal Ulcers Incidence: 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

20 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

21 Dumping Syndrome Incidence: 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

22 Vitamin B12 Deficiency Symptoms: 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 B mg IM Qmonth for life Vitamin B mg SL daily

23 Folic Acid Deficiency Incidence: 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

24 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

25 Zinc Deficiency Symptoms: poor wound healing, hair loss, nausea, impaired smell, impaired taste Supplements: Zinc 15mg po daily

26 Follow-up monitoring is key!

27 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

28 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

29 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

30 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


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