Bariatric Surgery

Bariatric Surgery Indian Medical PG Question 1: Dumping syndrome can occur after

• A. Whipple's operation
• B. Nissen fundoplication
• C. Heller's operation
• D. Billroth-II operation (Correct Answer)

Bariatric Surgery Explanation: ***Billroth-II operation*** - This procedure involves a **gastrojejunostomy** where the stomach is connected directly to the jejunum, bypassing the duodenum. This design allows for rapid emptying of gastric contents into the small intestine. - The rapid transit of **hyperosmolar chyme** into the small bowel draws fluid into the lumen, leading to symptoms like abdominal pain, bloating, diarrhea, and vasomotor symptoms (e.g., palpitations, sweating) [1]. *Whipple's operation* - While it involves extensive gastrointestinal reconstruction, a **Whipple's operation** (pancreaticoduodenectomy) typically includes a gastrojejunostomy that is less prone to severe dumping than a Billroth II, as it often preserves a significant portion of the duodenum or creates a more controlled gastric outflow. - The primary aim of a Whipple is to resect the head of the pancreas, duodenum, gallbladder, and bile duct, with subsequent reconstruction involving multiple anastomoses, but usually not one specifically designed to rapidly empty into the jejunum without duodenal transit. *Nissen fundoplication* - This procedure is performed to treat **gastroesophageal reflux disease (GERD)** by wrapping the top of the stomach (fundus) around the lower esophagus to strengthen the lower esophageal sphincter. - It aims to prevent reflux, not to alter the rate of gastric emptying in a way that typically causes dumping syndrome. *Heller's operation* - **Heller's myotomy** is a surgical procedure to treat **achalasia**, a disorder where the lower esophageal sphincter fails to relax properly. It involves cutting the muscle fibers of the lower esophageal sphincter to facilitate the passage of food into the stomach. - This operation addresses a motility issue of the esophagus and generally does not affect gastric emptying in a manner that leads to dumping syndrome.

Bariatric Surgery Indian Medical PG Question 2: Patient with BMI 40 presents for emergency surgery. All are correct about airway management EXCEPT:

• A. Extended ramping
• B. Avoid cricoid pressure (Correct Answer)
• C. Rapid sequence induction
• D. Avoid preoxygenation

Bariatric Surgery Explanation: ***Avoid cricoid pressure*** - While **cricoid pressure** (Sellick's maneuver) is used to prevent **aspiration** by compressing the esophagus, its effectiveness in **obese patients** is highly debated and often hindered by excess neck tissue. - In obese patients, cricoid pressure can actually worsen the view during laryngoscopy, making intubation more difficult and potentially causing airway trauma. *Extended ramping* - **Ramping** the patient, where the head and shoulders are elevated, is crucial in **obese patients** to align the **oral, pharyngeal, and laryngeal axes**. - This position improves the view during laryngoscopy and facilitates successful intubation by effectively displacing excess tissue. *Rapid sequence induction* - **Rapid sequence induction (RSI)** is often indicated in **obese patients** undergoing emergency surgery due to their increased risk of **gastric reflux** and **pulmonary aspiration**. - RSI involves administering a sedative and a paralytic agent in rapid succession, followed immediately by intubation, to minimize the time the airway is unprotected. *Avoid preoxygenation* - **Preoxygenation** is essential in **obese patients** to maximize their **oxygen reserves** before intubation. - Obese patients have reduced **functional residual capacity (FRC)** and increased **oxygen consumption**, making them desaturate rapidly during apnea, so preoxygenation significantly prolongs safe apnea time.

Bariatric Surgery Indian Medical PG Question 3: All of the following are primarily restrictive operations for morbid obesity, except which of the following?

• A. Laparoscopic adjustable gastric banding
• B. Roux-en-Y operation (Correct Answer)
• C. Vertical band gastroplasty
• D. Duodenal switch operation

Bariatric Surgery Explanation: **Roux-en-Y operation** - The **Roux-en-Y gastric bypass** is considered a **malabsorptive as well as a restrictive procedure** because it creates a small gastric pouch and bypasses a significant portion of the small intestine. - This dual mechanism leads to greater weight loss compared to purely restrictive surgeries. *Vertical band gastroplasty* - **Vertical band gastroplasty** is a **purely restrictive procedure** that creates a small pouch and restricts outflow, but does not involve nutrient malabsorption. - It is less commonly performed now due to higher rates of weight regain and complications compared to other bariatric surgeries. *Laparoscopic adjustable gastric banding* - **Laparoscopic adjustable gastric banding** is a **purely restrictive procedure** where an inflatable band is placed around the upper part of the stomach to create a small pouch. - This limits the amount of food that can be consumed at one time and slows gastric emptying, but does not alter nutrient absorption. *Switch duodenal operation* - The **duodenal switch operation** (biliopancreatic diversion with duodenal switch) is primarily a **malabsorptive procedure** with a restrictive component. - While it includes creation of a small gastric pouch, its most significant effect on weight loss comes from bypassing a large portion of the small intestine, leading to **significant malabsorption**.

Bariatric Surgery Indian Medical PG Question 4: A 50-year old lady underwent uneventful bariatric surgery for morbid obesity. On the third post operative day, she develops breathlessness and pulmonary embolism is suspected. The next investigation to confirm the diagnosis will be:

• A. MR angiography
• B. Echocardiography
• C. Duplex venography
• D. CT pulmonary angiography (Correct Answer)

Bariatric Surgery Explanation: ***CT pulmonary angiography*** - **CT pulmonary angiography (CTPA)** is the **gold standard** for diagnosing pulmonary embolism due to its high sensitivity and specificity in visualizing pulmonary arteries. - It rapidly provides detailed images of the pulmonary vasculature, allowing for the direct visualization of **thrombi** within the vessels. *MR angiography* - **MR angiography (MRA)** can be used for diagnosing pulmonary embolism but is generally less available and often takes longer than CTPA. - It is usually reserved for patients with contraindications to CT, such as **renal impairment** or **iodine allergy**, which are not indicated in this case. *Echocardiography* - **Echocardiography** can help assess the **right ventricular strain** caused by pulmonary embolism, but it is not diagnostic for the embolism itself. - It is more useful in evaluating the **hemodynamic impact** of the PE and ruling out other cardiac causes of breathlessness. *Duplex venography* - **Duplex venography** (or ultrasound of the lower extremities) is used to detect **deep vein thrombosis (DVT)** in the legs. - While DVT is a common cause of pulmonary embolism, this investigation does not directly visualize the embolism in the **pulmonary arteries**.

Bariatric Surgery Indian Medical PG Question 5: Which of the following is not a known complication associated with the procedure done in the patient?

• A. Aspiration
• B. Pneumothorax
• C. Refeeding (Correct Answer)
• D. Arrhythmia

Bariatric Surgery Explanation: ***Refeeding*** - The image shows a **central venous catheter (CVC)**, likely in the internal jugular vein. While CVCs are used for administering nutrition such as **total parenteral nutrition (TPN)**, refeeding syndrome is a metabolic complication that occurs when nutrition is reintroduced too quickly in severely malnourished patients. - **Refeeding syndrome is NOT a direct complication of the CVC insertion procedure itself**—it is a systemic metabolic complication related to the nutritional intervention (characterized by severe shifts in fluids and electrolytes, particularly hypophosphatemia, hypokalemia, and hypomagnesemia). - Therefore, refeeding is **not associated with the procedure** of CVC insertion. *Pneumothorax* - **Pneumothorax** is a well-recognized mechanical complication of central venous catheterization, particularly with subclavian and internal jugular vein approaches. - Occurs due to accidental puncture of the **pleura** during needle insertion, allowing air to enter the pleural space and causing lung collapse. - Incidence ranges from 1-6% depending on the site and operator experience. *Arrhythmia* - **Cardiac arrhythmias** are a known complication during CVC insertion when the guidewire or catheter tip inadvertently advances too far into the heart chambers (right atrium or ventricle). - Mechanical irritation of the myocardium can trigger **premature ventricular contractions (PVCs)** or other arrhythmias. - Usually transient and resolve upon withdrawing the catheter to proper position. *Aspiration* - While **aspiration** can occur in critically ill patients who require CVCs (due to altered consciousness, dysphagia, or ventilator-associated issues), it is **not a direct mechanical complication of the CVC insertion procedure itself**. - Aspiration relates to patient condition rather than the catheter placement technique, though both may coexist in the same clinical scenario.

Bariatric Surgery Flashcard 1 of 5

Question: _____ is the most common cause of death in patients of bariatric surgery

Answer: Pulmonary embolism

Bariatric Surgery Flashcard 2 of 5

Question: The following bariatric procedure is also known as _____

Answer: Roux-en-Y gastric bypass

Bariatric Surgery Flashcard 3 of 5

Question: _____ following laparoscopic sleeve gastrectomy are often difficult to treat, they are called the Achilles heel of the operation

Answer: Leaks

Bariatric Surgery Flashcard 4 of 5

Question: Which bariatric procedure has the maximum weight loss?_____

Answer: Biliopancreatic diversion / Duodenal switch

Bariatric Surgery Flashcard 5 of 5

Question: The following bariatric procedure is also known as _____

Answer: biliopancreatic diversion