Perioperative management - Laparoscopic gastric bypass

Like all other approaches in the treatment of obesity, surgical measures are not addressing the cause of obesity because this is complex and still largely unknown. Based on the guidelines in developed countries, surgery is considered in patients with a BMI ≥ 35 kg/m² and severe comorbidities, such as diabetes, or a BMI ≥ 40 kg/m² and in whom conventional treatment regimens had proved unsuccessful.

The following parameters must be considered when choosing a procedure:

1. • Patients baseline weight (BMI)
   • Expected weight loss (EWL)
   • Compliance
   • Age
   • Family planning not yet completed in women
   • Comorbidities (particularly diabetes )
   • Surgical risk

Other factors to consider include:

1. • Gender
   • Occupation
   • Eating habits 

• Debilitating disease
• Pregnancy
• Lack of compliance
• Gastric and duodenal disorders 

Since bleeding in the gastric remnant cannot be treated endoscopically, laparoscopic gastric bypass is contraindicated in patients on

• lifelong anticoagulants (warfarin or ASA)
• chronic analgesics (ulcerogenic)

Risk evaluation plays a key role in bariatric surgery. In addition to the standard diagnostic workup (ECG, chest x-ray, lab panels), this always includes pulmonary function testing and assessment of the nutritional status. Endoscopy of the stomach is particularly important in resection procedures such as gastric bypass. Radiology , on the other hand, provides additional information only in around 5% of patients. Routine polysomnography is standard practice in US departments where between 77% and 88% of patients suffer from sleep apnea.

Preoperative measures with physical conditioning are initiated already prior to hospitalization: No smoking, liquid diet at least two days before admission (ideally two weeks) and discontinuation of medication that could increase the risk (metformin, oral anticoagulants etc.).
Preoperative intestinal preparation is also recommended in gastric bypass.  In general, preoperative hygiene measures are like those in other types of procedures, paying special attention to intertriginous areas, acute inflammatory crural ulcers, and diabetic changes in the lower extremities. Antithrombotic weight.adapted medication is initiated on the day of surgery.

The patients must be given comprehensive information since they will undergo an elective procedure. In addition to the general surgical risks associated with laparoscopy and the conversion to laparotomy, this must include the specific risks ranging from the intraoperative risks, short- and long-term sequelae through the need for transfusion and the mortality risk.  At present, there is no standard format for obtaining informed consent.

You can find a detailed informed consent example here.