Failure To Extubate following MBS usually indicates 1 of 2 things?
Pulmonary Embolism
An anastomotic leak
What is the most reliable initial sign indicating Anastomotic Leak?
Tachycardia
What Two Surgeries are Anastomotic Leaks Common In?
RYGB & BPDS (Multiple Anastomosis Sites)
What MBS complication causes chronic bloating, diarrhea, and malabsorption?
Small intestinal bacterial overgrowth (SIBO)
- Weeks to months after surgery
What MBS complication causes intermittent abdominal pain and postprandial satiety usually around 1 year after surgery?
Internal hernias (due to mesenteric defect from losing weight)
Usually occurring > 1 year postoperatively after the patient has reduced their BMI by 15 kg/m2
Recommended Vitamin Supplementation following MBS?
- 2 Adult Multivitamins (except for LAGB, only 1)
- VIT D 3000 IU (titrate to maintain levels above 30)
- CALCIUM 1200 to 1500 (SG, RYGB, LAGB)
- Calcium 1800 to 2400 (SADI / BPD/DS)
- IRON (18mg M / 60mg Fperiod)
- PROTEIN (60g daily)
- WATER (50 oz daily)
What is Plummer-Vinson Syndrome and why is it associated with RYGB?
Chronic iron deficiency (from MBS) can lead to a condition called Plummer-Vinson syndrome, which is characterized by significant microcytic anemia and esophageal webs
This is particularly prevalent in Roux-en-Y gastric bypass surgery, as the duodenum, which is the location for iron absorption, is bypassed
Approximately what % of MBS patients experience improvement/resolution of HTN, T2DM, HLD, and OSA?
80%
What % cancer mortality risk reduction is achieved following MBS? (especially in what 2 cancer types)
60%, Breast and Colon.
Why do some MBS patients (despite losing weight) need to increase Hypothyroid meds?
Malabsorption. Liquid forms or soft gels may be preferred
Following Malabsorptive MBS (including Sleeve Gastrectomy), which form of anti-coagulation is most suitable for VTE development within 4 weeks?
Parenteral (Lovenox)
May use Oral DOAC’s after at least 4 weeks of parenteral therapy.
Which Surgery is associated with Bile Acid Gastritis?
One Anastomosis Gastric Bypass
Dx of Exclusion
How do you diagnose SIBO?
Carbohydrate breath test.
Decreased absorption of carbohydrates causes fermentation of unabsorbed carbohydrates
What nutrient abnormalities are associated with SIBO?
B12 deficiency (due to competitive absorption with the host), and folate excess (over-synthesized by the excessive bacteria).
What MBS has the best long term weight loss, but also carries highest mortality and complication risk?
Duodenal Switch (Combination of Sleeve Gastrectomy and Intestinal Bypass)
*Reserved for Highest BMI’s 40 to 50+
Best MBS prior to an organ transplant?
Vertical Sleeve (promotes weight loss and doesn’t increase risk of malabsorption of future immunosuppressant meds)
Blood Glucose Range s/p MBS in hospital?
140-180 (need to avoid hypoglycemia & hyperglycemia)
Why Should GLP-1’s Be withheld 1 week (or 1 day) before MBS?
To prevent gastric regurgitation and aspiration risk.
Postprandial hyperinsulinemic hypoglycemia (PHH)
Initial treatment of PHH should focus on dietary modifications with a low carbohydrate, mixed diet. If Those Fail:
- Acrabose (Delays carb digestion and subsequent insulin secretion)
- Octreotide (Inhibits Insulin)
- CCB’s (Inhibits Beta cell glucose dependent release of Insulin)
- Diazoxide: Suppresses insulin secretion via β-cell channels.
Why is Lovenox preferred above Warfarin and/or DOAC’s for DVT’s following Malabsorptive surgeries?
Warfarin/Vit K Antagonist (Increased Risk of bleeding)
DOAC’s (decreased absorption)
Solution for GERD refractory to medical Tx after Sleeve Gastrectomy?
Conversion to RYGB
Is EGD safe after MBS?
Endoscopy is safe after surgery and can be used to evaluate for a stricture, H. pylori, and celiac disease.
Are NSAID’s an absolute contraindication following MBS?
Although NSAIDs should be avoided, if unavoidable, the use of proton pump inhibitors should be used concurrently.
ERCP (for biliary assessment) following MBS?
When the Duodenum is by passed (like in RYGB), then traditional ERCP is not possible.
Balloon-assisted enteroscopy & Laparoscopy-assisted ERCP or percutaneous gastrostomy (trocar access) can also be employed to directly access the biliary system
