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• 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, creating
a small pouch and a
narrow passage into
the larger remainder
of the stomach
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
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
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 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.
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
• Marginal ulcers
• Vitamin deficiencies
50% after RYGB
3 - 10%
many have this pre-op
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
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 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
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
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 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
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 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
Vitamin B12 Deficiency
Symptoms:
• Megaloblastic anemia
• Pancytopenia
(leukopenia,
thrombocytopenia)
• Irritability, personality
change
• Mild  memory
• Depression
• Psychosis
• Paresthesias
• Peripheral Neuropathy
• Demyelination of
dorsal column and
corticospinal tract
• Increased risk of
myocardial infarction
and stroke
Prevention: Vitamin B12 1000mg IM Qmonth for life
Vitamin B12 1000-2000mg SL daily
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
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!
6
Months
12
Months
18
Months
24
Months
Annual
Complete blood count
X
X
X
X
X
Chemistry panel
X
X
X
X
X
Iron studies
X
X
X
X
X
Magnesium
X
X
X
X
X
Albumin
X
X
X
X
Vitamin B12
X
X
X
X
X
Vitamin D
X
X
X
X
Other fat-soluble
vitamins
X
X
X
Test
Parathyroid hormone
X
X
X
Folate
X
X
X
Bone density
X
X
X
Lipid panel
X
Uric acid
X
Vitamin K
X
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