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Case Study-Gastric Bypass

Case Study-Gastric Bypass

Case Study:  45yo wf with morbid obesity

Sarah Thomas is a 45-year-old woman who weighs 325 pounds and is 5’2″ tall. She has hypertension, controlled with Hyzaar, and osteoarthritis in her knees, limiting her ability to walk or exercise. She is scheduled in 4 weeks for a gastric bypass procedure.

  1. What is her body mass index (BMI)? How do you calculate a BMI? How much is she over the normal BMI?

Body mass index (BMI) measures body fat in adult men and women based on an individual’s weight and height (Zierle & Jan 2022). Sarah is a 45-year-old adult; therefore, BMI is used to measure her body fat. Body mass index is calculated using the formulae:

BMI = weight in kg 

Height² in meters

Or

BMI = weight in pounds    X 703

(Height in inches) ²

Weight = 325lbs

Height = 5’2″ tall, which is 5 feet and 2 inches.

Five feet translates to 60 inches; therefore, 5’2″ tall is 62 inches.

BMI = 325 X 703

(62) ²

= 59.4

Sarah’s body mass index is 59.4. An ideal and healthy BMI for adults ranges between 18.5 and 24.9. A BMI below 18.5 signifies underweight, while a BMI between 25 and 29.9 signifies overweight. A BMI between 30 and 39.9 shows obesity, while a BMI above 40 shows severe obesity (Zierle & Jan 2022). Sarah’s BMI of 59.4 is greater than 40; therefore, she is severely overweight. Sarah is over the normal BMI by 34.5:

59.4 – 24.9 = 34.5

  1. She is scheduled for a gastric bypass procedure. Identify at least two types of gastric bypass procedures and describe what is done in each and why.

Roux-en-Y gastric bypass is a type of gastric bypass procedure (Mitchell & Gupta, 2022). The patient is given a liquid diet before surgery to reduce the size of the liver. Roux-en-Y gastric bypass requires monitors adjusted at the start of the procedure to ensure the monitors can be viewed at eye level. The surgeon must comfortably use both hands during the procedure; therefore, the trocars are placed at least a fist length apart. Six trocars are used for the procedure. Two trocars are 5mm and four trocars are 10mm. The surgeon creates a window in the lesser sac to form a small gastric pouch. The stomach is stapled horizontally, followed by a vertical stapling towards the angle of His. The ligament of Treitz is exposed by retracting the transverse colon and the omentum. To bypass a Roux limb of 150 cm, the surgeon staples and transects the small bowel and its mesentery at the jejunum. The surgeon conducts a jejunojejunal anastomosis by sewing the enterotomy of the jejunojejunal anastomosis in a double layer. It is crucial to prevent internal hernias by closing the mesenteric defect. The Roux limb is revealed through antegastric and antecolic procedures. The surgeon performs a gastrojejunal anastomosis between the Roux limb and the pouch in a double layer to form an enterotomy and a gastrotomy. An orogastric tube is placed through the gastrojejunal anastomosis and submerged with irrigation fluid. The submerging and inflation of an orogastric tube with air are done to prevent any air leaks (Mitchell & Gupta, 2022).

Adjustable gastric banding is a gastric bypass procedure (Seeras et al., 2021). The surgeon and surgical team access and visualize the abdomen using a 5mm port that has a lens of 30 degrees. A 15mm and 5mm trocar is used in the working areas and placed at least a fist apart. The left lateral part of the liver is elevated using a Nathanson retractor and a 5mm first assistant port. The surgeon dissects the gastrophrenic attachments at the angle of His. A retrogastric tunnel is created by dissecting at the right crus. A band is placed through the 15mm trocar, retracted, and locked anteriorly. The surgeon creates a nasogastric plication using three sutures around the band and one suture below the band. It is crucial for the tubing to be connected to a port on the abdominal wall fascia. The procedure is completed by removing the trocars and Nathanson retractor and closing the incisions (Seeras et al., 2021).

  1. How does a gastric bypass procedure cause weight loss?

Gastric bypass is indicated in obese and overweight patients for sustained weight loss. Gastric bypass causes weight loss through a combination of malabsorption and gastric restriction. A patient who has undergone a gastric bypass experiences restriction caused by the small stomach pouch. The pouch ensures that the patient feels full and satisfied after taking a small amount of food. The surgeon creates a gastric pouch of about 20 ml and a small outlet during the procedure. When the pouch is distended by food, the patient experiences satiety. Gastric bypass causes weight loss through mild malabsorption by the separation of food. When a patient eats, the food will bypass the distal stomach, duodenum, and part of the jejunum. The rate of malabsorption depends on the length of the Roux limb. The longer the Roux limb, the more weight loss.

  1. What changes can be expected in the functioning of the G.I. tract following gastric bypass?

Gastric bypass decreases the stomach’s functional capacity and relaxation phase, leading to increased gastric emptying (Hui et al., 2022). Separating or removing the fundus causes decreased secretion of gastric hormones such as ghrelin. The secretion of ghrelin will gradually go back to normal post-surgery. Patients who have undergone a gastric bypass have an increased chewing time and a change in their perception of food. Gastric bypass causes increased secretion of glucagon and insulin by the pancreas. Gastric bypass of the jejunum and duodenum increases intestinal transit time and release of gut peptides. The large intestines experience changes in microbiota flora. Gastric bypass decreases the absorption of food throughout the gastrointestinal tract. The small intestine is the main site for absorption; therefore, decreased absorption leads to nutritional deficits.

  1. Describe what happens in ‘dumping syndrome’ and why it occurs.

Gastric bypass causes abnormal gastric motor function or alters gastric reservoir function, leading to dumping syndrome. Dumping syndrome is classified into early and late, depending on how soon the symptoms begin after a meal. Early dumping syndrome occurs 30 to one hour after a meal, while late dumping syndrome occurs one to three hours after a meal (Hui et al., 2022). In a normal individual, the stomach stores food and is a site for chemical digestion before food moves to the gastric antrum. Food in the gastric antrum is reduced to the desired particle size and moved to the pylorus. The pylorus allows the movement of small particles to the duodenum. Notably, the process of gastric emptying and movement of food from the stomach to the duodenum is altered by gastric bypass. Gastric resection decreases the size and capacity of the stomach to store food; therefore, the stomach stores less food. Removal or bypassing of the pylorus during a gastric bypass increases the rate of gastric emptying since food particles will move directly from the antrum to the duodenum. Gastric bypass alters mucosal function, leading to decreased enzymes and hormonal and acid secretions. Gastric bypass involves vagotomy or partial gastric resection, which decreases contractility. A decrease in contraction leads to the immediate movement of food from the stomach to the duodenum, termed dumping.

  1. What complications may occur specifically for gastric bypass surgical patients? Be sure to address more than the general surgical complications.

Complications of gastric bypass are categorized into early and late complications. Early complications of Roux-en-Y gastric bypass include pulmonary embolism, respiratory insufficiency, wound infection, pneumonia, acute enlargement of the distal stomach, anastomotic leak, and gastrointestinal bleeding. Late complications of Roux-en-Y gastric bypass include internal hernia, marginal ulcer, ventral hernia, cholelithiasis, stomal stenosis, staple line destruction, bowel obstruction, and micronutrient deficiencies (Seeras et al., 2022). Postoperative morbidity is a complication of gastric bypass. Stroke, hypertension, bleeding disorders, a history of myocardial infarction, and a higher body mass index increase the risk for postoperative morbidity. Gastric bypass causes weight loss by malabsorption, which can lead to nutrient and vitamin deficiency.

Early complications of adjustable gastric banding include bleeding, pneumonia, wound infection, food intolerance, and esophagus or stomach injury. Late complications of adjustable gastric banding include pouch dilatation, food intolerance, band infection, mortality, failure to lose weight, band erosion into the stomach, band slippage, reoperation, balloon leakage, port complications, esophageal dilatation, and postoperative mortality (Seeras et al., 2021).

  1. What follow-up should be done for the patient who has had gastric bypass surgery? (be sure to discuss issues of concern, time frame for follow-up, and suggestions on teaching/education that would be important for the patient and family to know)

A gastric bypass patient is monitored for a lifetime (Wilson & Rehman, 2022). The patient is scheduled for at least six follow-up appointments in the post-surgery year and three follow-up appointments in the consecutive years after the surgery. The initial follow-up is two to three weeks post-surgery, while the second visit is four to five weeks post-surgery. The number of follow-up appointments depends on the type of gastric bypass and the patient’s response. An adjustable gastric banding has more follow-up appointments than a Roux-en-Y gastric bypass for band adjustment (Seeras et al., 2021). In addition, the patient and their family are advised on wound care techniques postoperation to prevent infection and ensure proper wound healing. Also, malnutrition and deficiency are issues of concern that require patient education by a nutritionist. The patient and their family are advised on mineral, liquid protein, and mineral supplementation since gastric bypass causes their malabsorption in food. In addition, the nutritionist prepares an individual-specific meal plan for the patient. The meal plan is adjusted during the patient’s follow-up appointments. The initial adjustment to a new solid diet is made during the second follow-up post-surgery. During every appointment, the patient is screened for iron and vitamin deficiencies. The nutritionist monitors the patient’s weight loss journey to determine the procedure’s success.

Further, patients are highly susceptible to depression due to lifestyle changes, weight regains, slow weight loss, and eating disorders (Wilson & Rehman, 2022). As such, the patient’s family and friends are educated on how to support the patient. Additionally, the patient is scheduled for periodic counseling and recommended to gastric bypass support groups.

 References

Hui, C., Dhakal, A., & Bauza, G.J. (2022) Dumping Syndrome. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470542/.

Mitchell, B.G., & Gupta, N. (2022). Roux-en-Y Gastric Bypass. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK553157/.

Seeras, K., Acho, R.J., & Lopez, P.P. (2022) Roux-en-Y Gastric Bypass Chronic Complications. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519489/.

Seeras, K., Acho, R.J., & Prakash, S. (2021). Laparoscopic Gastric Band Placement. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK526062/.

Wilson, C., & Rehman, A. (2022). Counseling Patients on Bariatric Surgery for Obesity. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK572056/.

Zierle-Ghosh, A., & Jan, A. (2022). Physiology, Body Mass Index. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK535456/.

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Question 

Sarah Thomas is a 45-year-old who weighs 325 pounds and is 5’2″ tall. She has hypertension, controlled with Hyzaar, and osteoarthritis in her knees that limits her ability to walk or exercise. She is scheduled in 4 weeks for a gastric bypass procedure.   Answer the following questions related to this case study. Cite at least three sources in your answers and include a reference list in APA format on a separate page.

Case Study-Gastric Bypass

Case Study-Gastric Bypass

  1. What is her body mass index (BMI)? How do you calculate a BMI? How much is she over the normal BMI?
  2. She is scheduled for a gastric bypass procedure. Identify at least two types of gastric bypass procedures and describe what is done in each and why.
  3. How does a gastric bypass procedure cause weight loss?
  4. What changes can be expected in the functioning of the G.I. tract following gastric bypass?
  5. Describe what happens in ‘dumping syndrome’ and why it occurs.
  6. What complications may occur specifically for gastric bypass surgical patients? Be sure to address more than the general surgical complications.
  7. What follow-up should be done for the patient who has had gastric bypass surgery? (be sure to discuss issues of concern, time frame for follow-up, and suggestions on teaching/education that would be important for the patient and family to know)