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8/6/2019 Bariatric perioperative
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! Perioperative of the Bariatric Surgery
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Benefits of bariatric surgery
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Type of bariatric
surgery• Restrictive procedures
• Vertical banded gastroplasty (VBG)
• laparoscopic adjustable gastric banding (LAGB)
• Sleeve gastrectomy (SG)
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Vertical banded gastroplasty
Less complex and lower risk of micronutrient deficiencies
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Laparoscopic adjustable gastricbanding (LAGB)
Silicone band, can
be adjusted byaddition or removal
of saline
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Sleeve gastrectomy (SG)
Remaining size is about60-100 mL
For who high risk of performing a
gastric bypass orduodenal switch
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Type of bariatric
surgery• Malabsorptive procedures
• Biliopancreatic diversion (BPD)
• Duodenal switch operation (BPD/DS)
• Combination or mixed procedures
• Roux-en-Y gastric bypass (RYGB)
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Biliopancreatic diversion (BPD)
Creating a smaller
stomach
Distal part of smallintestine is connected
Bypassing duodenum and
jejunum.
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Biliopancreaticdiversion with
duodenal switch
Upper part of smallintestine are reattached at75–100 cm from colon
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Roux-en-Y stomachsurgery for weight loss
Stomach pouch is created with astapler device
Connected to the distal small
intestine.
Reattached inY-shaped
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Metabolic complications
of bariatric surgery• Acid-base disorder
• Bacterial overgrowth (primarily with BPD, BPD/DS)
• Electrolyte abnormalities (primarily with BPD, BPD/DS)
• Fat-soluble vitamin deficiency
• Folic acid deficiency Iron deficiency
• Osteoporosis Oxalosis
• Secondary hyperparathyroidism
• Thiamine deficiency (vitamin B1) Vitamin B12deficiency
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Executive summary of
recommendations• Which patients should be offered bariatric surgery?
• Which bariatric surgical procedure should be
offered?
• How should potential candidates for bariatricsurgery be managed preoperatively?
• System-oriented approach to medical clearance forbariatric surgery
• Early postoperative care (5 days)
• Late postoperative management (> 5 days)
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Which patients should be offered
bariatric surgery?
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Which patients should be offered
bariatric surgery?
• Depends on the available local-regional expertise
• Insufficient conclusive evidence to recommendspecific bariatric surgical procedures (Grade D)
• Should caution when recommending BPD, BPD/ DS, or related procedures (Grade C)
• Laparoscopic bariatric procedures are preferred
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How should potential candidates for bariatric
surgery be managed preoperatively?
• Discussion risks and benefits, procedural options
• Provided with educational and access to
preoperative educational sessions.
• Diabetes
• Targets HbA1c < 7.0% ,FBS < 110 mg/dL , 2hrPostprandrial <140 mg/dL
• Thyroid : routine screening not recommend
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• PCOS and fertility
• Minimize risk of pregnancy for at least 12mo
• Estrogen should be discontinued beforebariatric surgery
• 1 cycle :premenopausal
• 3 wks of HRT in postmenopausal
women) reduced thromboembolism
• Women with PCOS their fertility statusmay be improved postoperatively
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• Exclusion of endocrine causes of obesity
• Routine laboratory testing :not cost-effective and notrecommended, should based on Hx and PE
• Cardiology and hypertension
• Pt with heart disease should have cardiologyconsultation
• At risk for heart disease should undergo evaluation forperioperative beta-adrenergic blockade (Grade A)
• Pulmonary and sleep apnea
• Patients with intrinsic lung disease or disordered sleep
patterns• ABG and polysomnography,
• Stop smoking at least 8 weeks before bariatric surgery
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• Venous disease
• Risk or Hx of DVT or cor pulmonaleshould undergo diagnostic evaluationfor DVT (Grade D).
• Prophylactic vena caval filter (Grade C)
• Hx of prior PE, prior iliofemoral DVT
• Hypercoagulable state
• Increased right-sided heart pressures
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• Psychiatric
• Psychosocial-behavioral evaluation,which assesses environmental,familial, and behavioral factors
• Evaluation ability to incorporatenutritional and behavioral changesbefore and after bariatric surgery
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Early postoperativecare
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• Clear liquid meal program can usually be initiatedwithin 24 hours after any of the bariatric procedures
• Protein intake average 60 to 120 g daily (Grade D).
• Concentrated sweets should be avoided after RYGB tominimize symptoms of the dumping syndrome
• Nutritional supplementation
• 1-2 multivitamin-mineral supplements
• iron, 1200 to 1500 mg/d of calcium, and vitaminB-complex.
• PN should be considered in high-risk patients
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• Diabetes
• Insulin secretagogue drugs should be discontinued
• Maintain postprandial values below 180 mg/dL
• FBS maintained 80-110 mg/dL with the use of a long-acting insulin analogue
• In the ICU glucose levels should maintained 80-110 byintravenous insulin infusion (Grade A)
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• Pulmonary
• Aggressive pulmonary toilet and incentive spirometry, avoid hypoxemia,and early institution CPAP when clinically indicated
• Prophylaxis against DVT is recommended for all patients (Grade B; BEL
2 [randomized]) and may be continued until patients are ambulatory(Grade D). Early ambulation is encouraged (Grade C; BEL 3).
• Prophylactic regimens
• sequential compression devices
• UFH or LMWH 3 days before and after bariatric surgery
• IVC filter placement in patients at high risk for mortality after PE orDVT
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• Monitoring for surgical complications
• New sustained PR>120 beats/min for longer than4 hours should raise suspicion anastomotic leak
• In clinically stable: meglumine diatrizoate(Gastrografin) upper gastrointestinal studies or CTmay identify anastomotic leaks
• Exploratory laparotomy in high clinical suspicionfor anastomotic leaks despite a negative study
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Late postoperativemanagement
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• Inadequate weight loss
• Loss of integrity of the gastric pouch in
gastroplasty or RYGB procedures
• Poorly adjusted gastric band
• Development of maladaptive eatingbehaviors or psychologic complications
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• Metabolic and nutritional management
• Routine metabolic and nutritional monitoring is recommendedafter all bariatric procedures (Grade A)
• advised to increase physical activity to a minimum 30 min/day aswell as increase physical activity
• Association of malabsorptive surgical procedureswith nutritional deficiencies
• recommended empiric vitamin and mineral supplementationafter malabsorptive bariatric surgery
• Protein depletion and supplementation
• Protein intake 80 -120 g/d for BPD or BPD/DS and 60 g/d ormore for RYGB
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Skeletal and mineral
homeostasis, nephrolithiasis• Recommended evaluation Ca and Vit D metabolism
and metabolic bone disease in patients who have
undergone RYGB, BPD, or BPD/DS
• Ca, D2, D3 is indicated to prevent or minimizesecondary hyperparathyroidism without inducingfrank hypercalciuria
• Severe vitamin D malabsorption, may need D2 orD3 as high as 50,000 to 150,000 U daily
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• Bisphosphonates consideration in patients with Tscore 2.5 or below for the hip or spine only after therapy
for Ca and vitamin D insufficiency.
• Normal PTH level
• 25-OH D level of 30-60 ng/mL
• Normal Ca and PO4
• Urine24-hr Ca excretion 70-250 mg/24 h.
• Recommended dosages
• alendronate, 70 mg/ wk;
• risedronate, 35 mg/wk or two 75-mg tablets/mo; or• ibandronate, 150 mg/mo.
• zoledronic acid, 5 mg once a year
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Diagnostic testing and management
for skeletal and mineral disorders
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• Insufficient data to recommend empiric supplementationMg : 300 mg in women and 400 mg in men)
• Oral phosphate supplementation hypophosphatemia (1.5to 2.5 mg/dL), which is usually due to vitamin Ddeficiency
• Management of oxalosis and calcium oxalate stones
• avoidance of dehydration
• low oxalate meal plan
• oral calcium and potassium citrate therapy
• Probiotics containing Oxalobacter formigenes have beenshown to improve renal oxalate excretion and improvesupersaturation levels and may therefore be used as well
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Roux-en-Y gastric bypass
• Every 3-6 mo then Annually
• CBC, platelets, Electrolytes, Glucose, Lipid profile
• Iron studies, ferritin
• Thiamine RBC folate
• Vitamin B12 (MMA, HCy optional)
• Liver function (GGT optional)
• 25-Hydroxyvitamin D
• PTH
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Biliopancreatic diversion (+/-duodenalswitch)
• Every 3 mo Every 3-6 mo depending on symptoms
• Same + Fat-soluble vitamins (6-12 mo)
• Vitamin A, 25-OH D, Vit E, Vit K1 and INR
• Metabolic stone evaluation (annually) 24-Hour urinecalcium, citrate, uric acid, and oxalate
• Trace elements (annually or as needed)
• Zinc
• Selenium
• Miscellaneous (as needed)
• Carnitine Essential fatty acid chromatography
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Fat and fat-soluble
vitamin malabsorption• Routine supplementation of vitamin A is usually not
necessary after RYGB or purely restrictive procedures
• Routine screening for Vit A def is recommended
• Supplementation is often needed after malabsorptivebariatric procedures (BPD or BPD/DS)
• Routine screening for vitamin E or K deficiencies hasnot been documented for any bariatric procedure
• Fat-soluble vitamin deficiency
• Hepatopathy, coagulopathy, or osteoporosis
• Assessment of a vitamin K1 level should beconsidered
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Routine nutrient supplementationafter bariatric surgery
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Iron, Vitamin B12, Folic acid, andSelenium deficiencies
• Iron
• Should be monitored in all bariatric patients
• Ferrous sulfate, fumarate, or gluconate (320 mgbid) may be needed to prevent in malabsorptiveprocedure(Grade A)
• Vit C supplementation should be considered inrecalcitrant iron deficiency
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• Vitamin B12
• Evaluation Vit B12 deficiency in all patients
• Supplementation Vit B12 dosage of 350 mcg/d
• Parenteral supplementation if cant by oral
• 1000 mcg monthly or
• 1000 to 3000 mcg every 6 to 12 months
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• Folic acid
• Supplementation 400 mcg/d
• Should be provided in all women of childbearing age (Grade A)
• Nutritional anemia• should evaluate protein, copper, and
selenium if B12, folic and iron study isnormal
• Unexplained anemia or fatigue, persistent diar-rhea, cardiomyopathy, or metabolic bonedisease selenium levels should be checked
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• Zinc and thiamine• Inadequate evidence to empiric zinc
supplementation after bariatric surgery
• All bariatric patients should oralsupplement multivitamin that containsthiamine
• Protracted vomiting should screenedthiamine deficiency
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Gastrointestinal complications
• Diarrhea
• EGD with small bowel biopsies and aspirates
gold standard in the evaluation of celiac sprueand bacterial overgrowth
• Colonoscopy if the presence of Clostridiumdifficile colitis is suspected
• Persistent steatorrhea after BPD or BPD/DS shouldevaluation for nutrient deficiencies
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Gastrointestinal complications
• Stomal stenosis or ulceration after bariatricsurgery
• NSAIDS should be avoided
• H pylori testing• Anastomotic ulcers treated H2 blockers, PPI, sucralfate
• Persistent symptoms of GERD, chronic cough, orrecurrent aspiration pneumonia after LAGB suggestive
•
Band being too tight• Development of an abnormally large gastric
pouch above the band
• Immediate referral back to the surgeon
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Gastrointestinal complications
• Gallbladder disease
• Ursodiol 300 mg bid x 6 months postoperatively may beconsidered in patients not undergoing a prophylacticcholecystectomy (Grade A)
• No consensus need to perform cholecystectomy at the time of bariatric operations
• Bacterial overgrowth
• Suspected bacterial over-growth after BPD or BPD/DS should
be treated empirically with metronidazole
• For antibiotic-resistant cases : probiotic therapy withLactobacillus plantarum 299v and Lactobacillus GG mayconsidered (Grade D)
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Criteria for hospital admissionafter bariatric surgery
• Severe PEM should hospital admission for initiation of nutritionalsupport
• If not dehydrated, most patients can undergo endoscopic stomaldilation for stricture as an outpatient procedure
• Revision of a bariatric surgical procedure
• Complications from surgical procedure and not amenableor responsive to medical therapy
• Inadequate weight loss or weight regain in patients with
persistent weight-related comorbidities (restrictiveprocedure)
• Reversal of a bariatric surgical procedure is recommendedwhen serious complications cannot be managed medicallyand are not amenable to surgical revision
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