Chapter 57 Gastric Bypass (Case 39)
Case: A 37-year-old female presents for consideration of gastric bypass.
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) |
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):
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.
• 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.
Physical Examination
Specific examination findings requiring close attention include:
• Head and neck: Look for potential airway problems. Short neck. Prominent tonsils and adenoids. Enlarged thyroid.
• Respiratory: Check expiratory effort. Listen to both lung fields for inspiratory and expiratory wheezing.
• 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.
$50 | |
$150–400 | |
$150–2,000 | |
$150 | |
E6D $500 | |
Some centers prefer to perform an esophagogastroduodenostomy (EGD) to rule peptic ulcer disease. | H. pylori $50 |
$150–400 | |
• Physical therapy evaluation: Preoperative evaluation may help improve mobility before surgery and facilitate postoperative recovery.
Stay updated, free articles. Join our Telegram channelFull access? Get Clinical TreeGet Clinical Tree app for offline access |