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20 Cards in this Set

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When to use surgical treatment?
-Poor weight loss with:
Diet
Exercise
Behavior Modification
Pharmacotherapy
-meet criteria...
Timescale management obese adult
1) Lifestyle change
2) Drug treatment (at least 3 monthss)
3) if no 5% loss at least, surgery
Criteria for Surgical Selection and management (2,3,16, RAEN)
Class II with sig comorbidity
Class III
16-65 y.o.
Risk acceptable
Attempts unsuccessful
Expectations realistic
Informed/Motivated/committed
No substance abuse/pschosis
Popularity of treatment
900% increase in past decade
(lifelong follow-up, lifelong vitamin supp required)
2 Mechanisms of Surgery and defs
Restrictive: Delay digestion or reduce stomache size

Malabsorptive:(last resort) parts of intestines no longer invovled in digestion
Sleeve Gastrectomy
+ (effects good and bad)
(use before BPD/DS)
-Greater curvature of stomache is removed (gastric sleeve remains)
-gut hormones affected, but nutritional defficiency rare
Jejunoileal bypass (JIB)
Shortens gut, only fraction nutrients ingested aborbed but often reversed (20-50%!)
-MANY complications:
renal, bypass, hepatic, arthritis, metabolic)
Biliopancreatic Diversion and Duodenal Switch
-food diverted from bile and some digestive enzymes
-late nutritional problems possible! (calcium, parathyroid, fat soluble vits hypoalbuminemia)
-uncommon in US (HIGH RISK/BMI only)
Vertical Banded Gastroplasty
-Vertical staple line to create small gastric pouch, which can also be banded
-Absorptive function intact BUT staple line dehiscence, weight regain and vomiting possible (lots of revision/attention needed)
Laparoscopic Adjustable Gastric Band (LABG)/ Lap Band
-Silicon elastomer place around upper stomach to make small pouch (inflated or deflated as necessary)
-Delay gastric emptying and especially good diabetes
-but can cause prolapse gastric wall or vomiting
(good mild obese, diabetic, lifestyle conscious person)
LABG PROS x 3
lower complication
lowest mortality (but also done on lower risk, lower bmi ppl)
removable
Gastric Bypass definition
-Small gastric pouch + reroute directly to jejunum (bypass duodenum)
-RESTRICTIVE AND MALABSORPTIVE; limits gi emptying (but high calories foods cause discomfort now)
+weight loss for morbidly obese, resolve comorbidities often, fewer complications but
Gastric Bypass complications
GI leak
Internal hernia
thromboembolic events
Deficiencies in nutrition
Gastric Bypass results:
MOST COMMON
good early weight loss
IF Laparoscopically perforemd surgery even less pain, infection, hernia too!
Surgical Procedure Selection: Consider following
Individualized
magnitude of weight loss
related comorbidities
Diet adherence ?
behavior change?
Motivated?
Post-operative requirements:
Hydration and protein intake
Well defined diet progression (from liquid diet onward)
Micronutrient assessment
Multivit + calcium, Iron, Thiamine daily
Periodic assessment of BMD (bone mineral density)
Children obesity guidelines:
Achieved physiological maturity
BMI > 40, >35 sig disease (III or IId)
last resort
Intensive management
Fit for anesthesia and surgery
(acceptable b/c longer kid obese, higher chance comorbidity develop)
Characteristics affecting outcome (tons, see slides, last page)
last page, page 3
Surgery improvements on patient
Decrease comorbid condition
Increase QoL (esp cuase of sleep apnea, back pain, osteoarthritis)

(long-term improvement unknown, few followup study)
elements of successful surgery program
Multidisciplinary Team
Mental Health screening
full Consultation
Ongoing Staff training
Follow-up infrastructure
Outcomes tracking and reporting
standardized clinical protocols