BPD has the most profound effect on diabetes but caution is adviced in view of surgical risk and severe nutritional risk. If metabolic surgery is to be applied RYGB would be currently the best and safest option and should be done in the presence of preserved beta cell function. However there is an inverse relation between the size of the bougie and the rate of leaks. Use of size Fr as adviced by the sleeve consensus meeting may decrease leak without impacting excess weight loss. Most authors begin the section at cm from the pylorus, with the aim of improving gastric emptying by preservation of part of the antrum from the earlier concept of preserving cms of the entire antrum.
When using buttressing materials, never use a less than green load. When resecting the antrum, never use a less than green load. When performing revision surgery, firings should be green or larger. Oversewing is least costly but increases surgery time. Studies show it is beneficial when compared to doing nothing but may not be as efficacious as buttressing. However surgeons world over have used different techniques with respect to pouch creation, stoma, limb length, defect closure and use of band. Pouch creation should be vertically oriented in order to exclude the fundus which is the most distensible part of the stomach.
First firing during the creation of pouch should begin no more than 5cms distal to OG junction and volume is then reduced to 30 ml by vertical firing. Further reduction in volume has not been shown to increase weight loss or improve outcomes. Use of a mm circular stapler is associated with higher rates of stricture, and most surgeons prefer the use of mm circular staplers without significant difference in weight loss. A longer Roux limb at least cm may be associated with modest weight loss advantage in the short term in superobese but is of limited relevance to postoperative weight loss for the non- superobese patient.
The biliopancreatic limb is usually kept short less than 75 cm. Consequently, bariatric surgeons should pay more attention to the length of the common channel when constructing a gastric bypass especially in the superobese population where failure rates after conventional gastric bypass are higher. With antecolic approaches taking over as the preferred approach , the incidence of mesocolic hernia which was otherwise the commonest has reduced drastically. The closure of intermesenteric defects has huge impact on the incidence of internal hernias and the complications associated with it.
Closure of the Petersens hernia is controversial and although decreased the incidence of Petersens hernia, the overall incidence has not been reduced. The better the closure the better the outcome. Superior weight loss has been shown in banded bypass patients compared to the nonbanded bypass both in the short and long term. But increasing incidence of vomiting has been noted in this group. Currently, there is no consensus of opinion on the ring size to be used. However restrictive operations are quick procedures and less invasive than a bypass. Most would also not consider a RYGB because the bypassed stomach will be inaccessible should variceal bleeding develop especially at the fundus.
Can proceed if early cirrhosis, Childs A, no portal HT if OR if unexpected can take a biopsy and defer if not worked up. Polycystic ovarian disease: The pathophysiology is multifactorial and is characteristics any two of the following 1. As these patients have high incidence of impaired glucose tolerance and type 2 DM, DM profile has to be thoroughly done.
Hence bariatric surgery is more ideal in a morbidly obese GERD patients who requires a surgical management. It can be done with prior counselling and explanation to the patient about the possible recurrence of GERD over a long term and the issue of unkknown long term consequences of volume reflux. Hernia first approach 2.
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Bariatric first approach 3. Concomitant hernia with biological mesh 4. If chosen the omental plug in these hernia should not be removed. Prophylactic approach — Performing Lap Cholecystectomy in all patients at the time of initial surgery, regardless of the presence or absence of gall stones. Untreated OSA have hypoxemia during sleep and eventually over time develop pulmonary hypertension, cardiac arrhythmias and increased risk of mortality. Bariatric surgery patients with OHS who retain carbon dioxide are at risk for carbon dioxide retension and respiratory arrest due to carbon dioxide narcosis.
Gastrograffin study All bariatric surgeries come with an inherent risk of leak. In order to decrease morbidity and mortality associated with these complications, early detection is critical. Overall sensitivity for leak is very low. Clinical signs and symptoms consistent with leak prompted the CT swallow studies. These studies will generally assess technical issues, ie leaks secondary to early mechanical failure but not the later ischaemic leaks.
Healthy Weight/Obesity - Bariatric Surgery - Related Tools & Resources
Thus many suggest abandoning routine UGI in favor of following patients for development of symptoms. Early routine UGI allows for documentation of final operative anatomy. This may help evaluation of performance, especially for general surgeons in training being able to visualize internal anatomy following surgery allows for improvement in surgical skills.
Routine UGI will also show any transient causes of obstruction, such as hematoma or edema within the lumen that would prevent a patient from tolerating a diet and would change the management of patients in these cases. Based on this knowledge most bariatric surgery units are currently using higher than standard doses of heparin or LMWH for VTE prophylaxis which however varies from institution to institution.
Strongest data seem to support the use of 40 mg of enoxaparin SQ every 12 hours. The use of this dose was shown to decrease the risk of VTE in patients undergoing bariatric surgery compared to 0. Thus at weights less than kg standard 0. Safety of weight based dosing in bariatric surgery patients is not known. Higher doses of Fondaparinux of 5 mg in severely obese in a bariatric surgical setting may be required to achieve target anti-FXa levels. However because of the risk of bleeding without established reversal agent, higher doses should be should be used with caution.
It may be considered if a high bleeding risk precludes the use of pharmacologic prophylaxis in patients. It may reduce postoperative PE, particularly in high-risk bariatric surgery patients but insertion-related complications have been described and need to be considered. In most series prophylaxis was continued during hospitalizations, but with earlier discharges from the hospitals prophylaxis most recommend to continue prophylaxis for a total of 8 to 10 days. Extended pharmacologic thromboprophylaxis for up to 4 weeks after discharge may be warranted in certain high risk patients undergoing bariatric surgerybased n extraplated evidence.
In this article, the clinical practice guidelines are heuristically organized into categories of appropriate candidates, psychological evaluations, and postoperative intervention. Many of the updated guidelines are related to the appropriate types of medical patients for surgery, the role of specific surgeries, and nutritional considerations.
The SAGES Manual: A Practical Guide to Bariatric Surgery
Other recommendations concern matters such as informed consent. This article focuses on the psychological recommendations of the CPGs for bariatric patients.
A review of the updated CPGs may lead bariatric teams, and psychologists within them, to reconsider how and what psychologists do as part of the team. This article reviews 15 of the guidelines that appear most relevant to the psychologist, and are organized and presented in three broad categories: appropriate candidates, preoperative evaluation, and postoperative intervention. Within each category, reference will be made to the recommendation number, following the updated CPG. For example, the first recommended CPG is denoted as R1.
Quality of life QOL is a multidimensional concept that has been the focus of many researchers over the past 40 years. Early attempts to quantify QOL identified 15 components into five broad dimensions: physical and material well-being; relationships with other people; social, community, and civic activities; personal development and fulfillment; and recreation. Fayers et al argued that while some measures of QOL consist of items related to medical symptoms of disease states causal items , others reflect the level of quality effect items.
Some scales attempt to measure causal factors, while others measure the level of QOL effect items , although most scales combine the two. As psychologists, we are more concerned with the level of QOL effects than the symptoms of disease states that may cause them. Such a distinction is not always possible to make, as Fayers et al pointed out. There is even a journal devoted to the topic titled Quality of Life Research.
With so many choices, the decision of which instrument to use in determining QOL is a complex one. Kolotkin et al at Duke University have published extensively using this measure. Whichever measure used, psychologists can help identify that subset of appropriate patients whose QOL has been significantly affected by their weight. These CPGs reference both psychosocial and behavioral evaluation. Evaluations of this sort, distinguished from purely medical examinations, can be traced back to Engels, whose concept of psychosocial evaluations proposed a systems theory approach to evaluating the person, not only at a biomedical level, but also on personal, family, and social levels.
The decision of exactly which factors to include within the evaluation is open to interpretation and, to some extent, left to the discretion of the psychologist. My interpretation of the revised CPGs leads to the conclusion that a thorough assessment should include the following:. In conducting a psychological assessment, there is the need to gather important, relevant information and, at the same time, avoid being over-inclusive in what one gathers. Work or disability status is also seen as relevant, including education, career, and retirement.
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