What are the indications for bariatric surgery?
- BMI > 35
- BMI > 30 with any form of metabolic disease (including asthma, GERD, infertility/PCOS) and ineffective non-surgical treatment
What are contraindications to bariatric surgery?
- severe or end-stage cardiac or liver disease
- active malignancy
- inflammatory bowel disease
- uncontrolled nicotine/drug/alcohol dependency
Which patients do better with LRYGB than sleeve gastrectomy?
those with reflux
How should hiatal hernia be managed during bariatric surgery?
should repair these primarily
Describe sleeve gastrectomy technique.
- laparoscopic entry and port placement
- mobilization of the greater curve of the stomach extending from the angle of His to several centimeters proximal to the pylorus
- division of any retrogastric attachments
- placement of a bougie along the lesser curve
- stapled gastrectomy beginning 4-6cm proximal to the pylorus, avoiding narrowing the incisura
- intra-operative leak test
How is diet managed before and after sleeve gastrectomy?
- liquid diet for 1 week pre-op for liver reduction
- bariatric clear liquid diet at post-op check
- bariatric full liquid diet at 1 week post-op visit
How should new GERD after sleeve gastrectomy be managed?
- would generally get an UGI to rule out sleeve stricture or stenosis as a contributing factor
- okay for trial of PPI
- but if fails to resolve, next step is generally conversion to LRYGB
- alternatives include Hill gastropexy to pre-aorta fascia if there is recurrent hiatal hernia
- or a LINX procedure to augment LES
How does LRYGB reduce reflux?
- excludes most parietal cells from the pouch
- forms a long roux limb that prevents biliary reflux
- weight loss also reduces intra-abdominal pressure
The roux limb is another name for what?
the alimentary limb of a bypass
Describe the technique for LRYGB.
- supine positioning
- laparoscopic access (right upper/middle/lower quadrants, LUQ, left hemiabdomen)
- exploration of hiatus with repair of hernia if present
- division of jejunum 50cm from LOT
- creation of a 100cm roux limb and jejunojejunostomy
- closure of mesenteric defect
- gastric mobilization and liver retractor
- creation of 25mL lesser-curve based pouch
- stapled gastrojejunostomy with 45mm linear stapler
- passage of 32F bougie across the common channel
- closure of channel over the bougie
- leak test
- closure of Petersen’s defect
How is the gastric pouch created during LRYGB?
- fire transversely, beginning 5cm below the GEJ
- then fire superiorly, angled toward the angle of His and the left crus until division is complete
- should form a 25mL, lesser curve-based pouch
Which patients undergoing bariatric surgery should get a cholecystectomy?
no role for prophylaxis, would only perform if having symptomatic cholelithiasis at the time of initial operation
If you are performing bariatric surgery and note cirrhosis on abdominal entry, what are next steps?
decision to proceed is based on safety and whether there is significant splenomegaly and varices that would preclude operation (safe answer is to abort)
What should you do if having trouble getting the roux limb to reach the GJ in a LRYGB?
- can divide the omentum to create a space for the limb
- can bring up the limb in a retrocolic position to reduce tension
- can create a longer pouch although this increases the risk of a subsequent ulcer
Why perform EGD before all bariatric surgery?
- evaluates for hiatal hernia
- evaluates for signs of reflux in patients without symptoms of reflux
Why consider ventral hernia repair at the time of LRYGB?
because there isa. risk of herniation and incarceration of an ante colic roux limb
What is the preferred operation for perforation of a marginal ulcer in someone with a gastric bypass?
- consider primary repair
- perform omental patch
- wide drainage
- remnant gastrostomy
What is the differential for abdominal pain after gastric bypass?
- marginal ulcer
- stricture
- internal hernia
What are the different mesenteric defects after a LRYGB?
- mesocolic defect for those with a retrocolic bypass
- Petersen hernia between the roux limb and transverse colon
- mesomesenteric defect of the JJ
What is the workup algorithm for pain in someone with gastric bypass?
- KUB to look for free air
- CT A/P with PO contrast to look for leak/perforation and internal hernia
- UGI series to further evaluate for internal hernia
- EGD to evaluate for ulcer
What is the treatment for a marginal ulcer in someone with a history of gastric bypass?
- test for and treat H. pylori
- evaluate for NSAID use or tobacco use and counsel on cessation
- start a PPI and sucralfate
- repeat EGD in 6-8 weeks to assess for healing
- if still not better, will need a revision
What is the port configuration for diagnostic laparoscopy after gastric bypass?
- Veress entry in the LUQ
- 12mm port right of the umbilicus
- 5mm port in the RUQ
- left paramedian assistant port
What should raise the suspicion for an ectopic pregnancy?
B-hCG level > 3000 without an identifiable intra-uterine gestational sac
What are the criteria for and what is the medicine used for medical management of ectopic pregnancy?
- use methotrexate
- indicated for those with a b-hcg less than 10,000 and no fetal heart tones
- otherwise, require surgical intervention
