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* Adjustable gastric banding
* Vertical banded gastroplasty
* Vertical sleeve gastrectomy
•
* Roux-en-Y gastric Bypass

• 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

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

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

• 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

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.

• 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
Laproscopic
10 -15%
3 - 4%
• Small bowel obstruction 1 - 2%
Later Complications
• Dumping Syndrome
• Marginal ulcers
50% after RYGB
3 - 10%
• Vitamin deficiencies many have this pre-op

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

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Venous stasis
– Prolonged immobility
– Vascular Injury
Hypercoagulability
– Cancer
– Use of BCP
– MI / A fib
– COPD
– Obesity

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

• 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

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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

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

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

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

( 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

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

• 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

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

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

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

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

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

Test
Complete blood count
Chemistry panel
Iron studies
Magnesium
Albumin
Vitamin B12
Vitamin D
Other fat-soluble vitamins
Parathyroid hormone
Folate
Bone density
Lipid panel
Uric acid
Vitamin K
6
Months
X
X
X
X
X
X
X
12
Months
X
X
X
X
X
X
X
X
X
X
X
X
X
X
18
Months
X
X
X
X
X
X
24
Months
X
X
X
X
X
X
X
X
Annual
X
X
X
X
X
X
X
X
X
X
X
X
X

• 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