Sunny Shah, MS IV

HPI
45 y/o Female with PMH of Anxiety, GERD, and Anemia presents to BMH
for elective laparoscopic gastric band and port removal. Patient has been
complaining of chronic GERD and associated Nausea over the last one
year. According to patient the problem occurs constantly and has been
unchanged. Patient denies abdominal pain, chest pain, congestion,
coughing, fatigue, fever, myalgias, or vomiting. Nothing aggravates the
symptoms and patient denies any management of her symptoms.
PMH

Anxiety, GERD, and Anemia.
Past Surgical History
-Laproscopic Gastric Banding Before 2009? As per Radiology
Report from GI series in 2009 patient has History of Gastric
Banding
-Gastric Bypass- Before 2009? As per Radiology Report From GI
series in 2009 patient was reported as S/P Gastric Bypass
-C-Section Procedure-?
-Tonsillectomy- 1976
-Appendectomy- 1971
Social History
-No smoking History
-Socially Drinks Alcohol- unknown amount
Family History
-Unknown
Allergies
-NKDA
Medication
-clonazepam .5mg PO at bedtime
-Fluoxetine 40mg PO 1X/day
-Pantoprazole 40mg PO 1X/day

ROS
Constitutional: Positive for weight loss. Negative for fever
and fatigue.
HENT: Negative for congestion.
Respiratory: Negative for cough.
Cardiovascular: Negative for chest pain.
Gastrointestinal: Positive for nausea. Negative for
vomiting and abdominal pain.
Musculoskeletal: Negative for myalgias.


Physical Exam
Vitals : 119/72; 55 bpm; temp 36.1; RR 18; BMI: 21.4 (Weight 121pds; Ht: 53)
Constitutional: She is oriented to person, place, and time. She appears well-
developed and well-nourished.
HENT:
Head: Normocephalic and atraumatic.
Right Ear: External ear normal.
Left Ear: External ear normal.
Eyes: Conjunctivae and EOM are normal. Pupils are equal, round, and reactive to
light.
Neck: Normal range of motion.
Cardiovascular: Normal rate, regular rhythm and normal heart sounds.
Pulmonary/Chest: Effort normal and breath sounds normal.
Abdominal: Soft. Bowel sounds are normal.
Musculoskeletal: Normal range of motion.
Neurological: She is alert and oriented to person, place, and time. She has
normal reflexes.
Skin: Skin is warm and dry.
Psychiatric: She has a normal mood and affect. Her behavior is normal.
Judgment and thought content normal.


LABS on 6/20 (4:00AM)

CBC
WBC: 5.9
RBC: 4.70
HBG: 8.9 L
Hematocrit: 29.6 L
MCV: 62.9 L
Platelets: 367
BMP
Glucose: 87
BUN: 14.0
Creat: 0.60
Calcium: 10.1
Sodium: 142
Potassium: 4.1
Chloride: 104
CO2: 24
Anion Gap 14.0


On 05/23/2014
-Significant gastroesophageal reflux and esophageal
dilatation. Significant narrowing of the stomach at
the level of the band. The appearance has not
changed significantly since the previous study.
On 3/29/2011:
- Significant narrowing at the level of the lap band
with dilatation of the gastric pouch and esophagus
and significant gastroesophageal reflux. Possible
ulceration or diverticulum at the inferior aspect of the
pouch.
On 3/06/2009:
- After oral administration of Gastrografin noted
evidence of gastric banding. No leak. Flow of contrast
is normal.




45 y/o F s/p Laparoscopic Gastric Banding
presents with significant GERD and nausea
over the last year due to partial stomal
obstruction and esophageal dilation.
Patient has opted for elective laparoscopic
gastric band and port removal
Hospital Course:
Evolution/Complication: No complications noted
during procedure
Condition Upon Discharge:
-Vitals stable, tolerating clear liquid diet, pain well
controlled.
-Abd was soft, nondistended, dressing over incision
was clean and dry.
-Discharged the following day, 06/21/2014, on
oxycodone-acetaminophen 5-325 mg PO Q6 as
needed with f/u in general surgery clinic in 1 week.
-Told to avoid strenuous exercise and sports and stay
clear liquid diet.


Restrictive and Malabsorptive
*Roux-en-Y Bypass
*Adjustable LAP BAND
Restrictive
Sleeve Gastrectomy with
Duodenal Switch
Restrictive and Malabsorptive

Roux-en-Y gastric bypass
Advantages
Rapid initial weight loss: >30-40% w/in 6 mo.
Laparoscopic approach is possible
Takes 1-2 hours


Disadvantages
Stomach cutting, stapling and intestinal re-
routing required
Portion of digestive tract is bypassed, resulting in
nutritional deficiencies
Dumping syndrome can occur
Non-adjustable
Extremely difficult to reverse
Upto 16% of patients
Occur near the gastrojejunostomy acid injuring the jejunum
Due to:
1)poor tissue perfusion (ischemia @ the anastomosis)
2)Foreign material (staples or nonabsorbable suture)
3)Excess acid exposure (to gastric pouch )
4)NSAIDS
5)H. Pylori
6) Smoking
Presentation
Nausea, pain, Bleeding and/or perforation
Up to 38% of patients within 6 months post-op
Bile stasis leads to increased sludge and
gallstones
Prophylactic cholecystectomy prior to surgery
(controversial) but some surgeons recommend
if symptomatic gallstones preoperatively
Prophylactic use of ursodiol (ursodeoxycholic
acid)frequency of cholelithiasis reduced to
2%)
Up to 50% post-op
When high levels of simple carbohydrates are
ingested
Early type: Rapid onset (w/in 15 min)due to
rapid emptying of food into small bowel
Late Type: result of hyperglycemia and
subsequent insulin response causes
hypoglycemia
LAP-BAND
Advantages
Lowest mortality and complication
rate
Least invasive surgical approach
No stapling, cutting, or intestinal
re-routing
Adjustable
Reversible
Low malnutrition risk
Disadvantages
Slower initial weight loss than
Gastric Bypass
Regular follow-up critical for
optimal results: Need adjustments
Requires implanted medical device

Source: OBrien et al. Obesity is a Surgical Disease: Overview of Obesity and
Bariatric Surgery, ANZ J Surg, 2004; 74: 200-204.
EARLY
Acute Stomal
Obstruction
Band Infection
Gastric Perforation
Hemmorrage
Broncopneumonia
Delayed Gastric
Emptying
Pulmonary
Embolism
Late
oBand Erosion
oBand Slippage/Prolapse
oPort or tubing
Malfunction
oLeakage at port site
tubing or band
oPouch or esophageal
dilation
oEsophagitis
Sleeve Gastrectomy:
-Significant Restriction component
-Pyloric Valve preserved Decrease in dumping
syndrome
-Decrease in Ghrelin (hunger hormone)
removed with greater curvature of stomach

Disadvantages:
-Demanding to perform
-Nutritional deficiencies afterwards
Symptoms of Dysphagia, vomiting, dehydraption,
and inability to tolerate an oral diet.

Occurs common at gastroesophageal junction and
the incisura angularis
Most Common Reasons: over sewing the staple
line and using a bougie to the too small (debatable
but normally ranges from 30-60 French)

Up to 7-10 days after surgery ( up to 5% of
patients)
Most common at gastrojejunostomy,
enteroenterostomy, Roux limb stump, staple line
Can lead to peritonitis, sepsis, possible death
Presentation
Tachycardia, tachypnea
Fever
Abdominal pain/back pain
Pelvic pressure or rebound tenderness
Order Gastrograffin upper GI series
Subclinical cases
Bowel rest
Parenteral nutrition
IV antibiotic if H. pylori
Clinically suspect leak
Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause of
preventable injury, major long-term disabilit,y
or death in bariatric surgical patients
Iron deficiency anemia
B12 deficiency
Folate deficiency
Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries
Common following RYGB
As high as 49% of patients (esp. menstruating
women)
Multifactorial cause
Low gastric acid levels prohibit iron cleavage from food
Absorption inhibited because no nutrient exposure to
duodenum or proximal jejunum
Decrease in iron-rich food consumption due to intolerance
Treat with oral supplementation of ferrous sulfate
or ferrous gluconate

Up to 70% of patients
Lack of hydrochloric acid and pepsin in
stomach
Prevents B12 cleavage from food
Affects secretion of intrinsic factor, thus B12
absorption
Intolerance to meat and milk
Oral supplementation usually adequate,
otherwise, IM injections used
Folate Deficiency (complete absorption
requires B12)


Vitamin D deficiency is common among obese
people
Calcium absorption decreased because duodenum
is bypassed
Intolerance to dairy, foods high in calcium
Vitamin D is required for Ca
++
absorption
Prolonged deficiencies lead to
Bone resorption, osteomalacia, osteoporosis
Treat with calcium citrate supplementation and 2
weekly doses of Vitamin D
Vitamins and Medications after Surgery
(REQUIRED for LIFE)
Gastric Bypass
2 chewable
multivitamins daily (ex:
Flinstones)
Calcium Citrate or Tums
1000 mg daily
Vitamin D 800 iu daily
Vitamin B 12 250 mcg
daily
Ferrous Sulfate elixir 325
mg daily (menstruating
women only)

Band
2 chewable
multivitamins daily (ex:
Flinstones)
Calcium Citrate or Tums
1000 mg daily
Vitamin D 800 iu daily


REFERENCES
1)Lim RB, Blackburn GL, Jones DB. Benchmarking best practices in
weight loss surgery. Curr Probl Surg 2010; 47:79.
2)Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011.
Obes Surg 2013; 23:427.
3)Lomanto D, Lee WJ, Goel R, et al. Bariatric surgery in Asia in the last
5 years (2005-2009). Obes Surg 2012; 22:502.
4) Brolin RE, LaMarca LB, Kenler HA, Cody RP. Malabsorptive gastric
bypass in patients with superobesity. J Gastrointest Surg 2002; 6:195.
5)Uptodate article: Bariatric surgical operations for the management of
severe obesity: Descriptions. Author: Robert B Lim, MD, FACS, LTC, MC,
USA. Section Editor: Daniel Jones, MD. Deputy Editor: Rosemary B
Duda, MD, MPH, FACS