Gastric Bypass (Case 39)

Chapter 57 Gastric Bypass (Case 39)

Lisa R. Weisfelner, MD, Andres E. Castellanos, MD

Case: A 37-year-old female presents for consideration of gastric bypass.

Obesity Comorbidities

The following are among the most common comorbidities to be considered when evaluating a patient for gastric bypass:
Diabetes Sleep apnea Depression
Hypertension Joint paint Gastroesophageal reflux disease (GERD)

Speaking Intelligently

When I encounter a patient requesting gastric bypass surgery, I must determine if the patient is a good candidate for the procedure. I consider body mass index (BMI) and medical comorbidities, and I follow the recommendations of the National Institutes of Health (NIH) and the American Society for Metabolic and Bariatric Surgery (ASMBS).

The most important criterion after BMI is personal motivation to change current lifestyle. To select the right candidate for surgery, I rely on a multidisciplinary approach, which includes seeking the advice of a nutritionist and a psychologist.

PATIENT CARE

Clinical Thinking

• Obesity is a chronic disease with comorbid factors worsening over time. Important comorbidities recognized in obese patients are type II diabetes, hypertension, arthritis, sleep apnea, hypercholesterolemia, and GERD.
• Ideal body weight tables, waist circumference, or BMI are used to qualify patients for surgery. BMI, which is used most often, is a measurement of weight adjusted for height and is measured in kg/m2, calculated by the following formula (note conversion for pounds and inches):

image

Categories of BMI:

Category BMI
Normal 18.5–24.9
Overweight 25.0–29.9
Obesity  
Type I 30.0–34.9
Type II 35.0–39.9
Morbid obesity 40.0–49.9
Super-obesity >50
• Candidates for gastric bypass should have a body mass index (BMI) of 40 or higher, approximately 100 lb over ideal body weight
• In certain instances patients with BMIs between 35 and 40 may be considered for surgery if they have medical comorbidities likely to be ameliorated by gastric bypass (e.g., severe sleep apnea, obesity-related cardiomyopathy, severe diabetes).
• A good surgical candidate (1) meets criteria for morbid obesity, (2) has no endocrine cause of obesity, (3) is an acceptable operative risk, (4) understands the surgery and the risks, (5) has no drug or alcohol problem, (6) has no uncontrolled psychological conditions, and (7) is dedicated to lifestyle change and long-term follow-up.

History

• Ask why the patient is presenting to you for bariatric surgery. This should remain an open-ended question.
• An accurate picture of the patient’s weight problem should include the following:
• Initial onset, lowest and highest adult weight, effect of weight on daily life, and hx of eating disorder.
• Family hx of obesity.
• Current diet habits, including frequency and content.
• Diet medications and programs already tried with amounts lost and regained.
• Exercise hx, including physical limitations.
• Social hx should include marital status, family composition, support system, smoking, drug and alcohol hx, and identifiable stressors. If the patient has seen a mental health professional for any reason, this should be discussed and noted.
• The past medical hx should include a detailed hx of all comorbid conditions. Past surgical hx is important to assess the patient’s risk for general anesthesia.

Physical Examination

Performing a thorough physical examination in obese patients can be difficult and challenging. Look for signs of undiagnosed disease related to obesity.

Specific examination findings requiring close attention include:

• Head and neck: Look for potential airway problems. Short neck. Prominent tonsils and adenoids. Enlarged thyroid.
• Cardiovascular: Document the presence of edema and peripheral pulses.
• Respiratory: Check expiratory effort. Listen to both lung fields for inspiratory and expiratory wheezing.
• Abdominal: Note previous scars and abdominal wall hernias.
• Extremities: Morbidly obese patients are at risk for DVT (even pre-op and certainly postsurgery). Careful pre-op exam is required.

Tests for Consideration

Consultations and evaluations should be individualized.

• Nutrition consultation: Mandatory in all patients.
 $50
• Pulmonary evaluation: Most centers require pulmonary function tests. A formal sleep study may be required if the patient has sleep apnea.
 $150–400
• Cardiac evaluation: Based on hx and risk factors, an EKG, stress echo, or formal catheterization may be indicated.
 $150–2,000
• Psychological/psychiatric evaluation: Even though controversial, we believe that it is extremely important to r/o active emotional disorders that will jeopardize the success of the surgery.
 $150
• Gastric evaluation: In some instances it is important to r/o the presence of peptic ulcer disease. In some centers Helicobacter pylori testing is mandatory.
 E6D $500
Some centers prefer to perform an esophagogastroduodenostomy (EGD) to rule peptic ulcer disease. H. pylori $50
• Endocrine evaluation: May be indicated in particular situations to r/o metabolic causes of obesity or aid in the management of diabetes perioperatively.
 $150–400
• Physical therapy evaluation: Preoperative evaluation may help improve mobility before surgery and facilitate postoperative recovery.

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Mar 20, 2017 | Posted by in GENERAL SURGERY | Comments Off on Gastric Bypass (Case 39)

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