ZZarghamifard General surgeon amp fellowship of MIS Bariatric surgery preop preparation WHY Planning the surgery Patient safety Preop preparation Cardiac status VTE amp PE Sleep apnea amp obesity hypoventilation syndromeOHS ID: 1039228
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2. Bariatric surgerypreop preparationZ.ZarghamifardGeneral surgeon & fellowship of MIS
3. Bariatric surgerypreop preparationWHY?Planning the surgeryPatient safety
4. Preop preparationCardiac statusVTE & PESleep apnea & obesity hypoventilation syndrome(OHS)GI evaluationPsychiatric evaluationLab testUS
5. Cardiac statusIncreased risk of CAD in obesity especially in:Age >50 Hx of CADDMHyperlipidemiaHTN
6. Cardiac statusHx & Ph ExamECG: increased QT interval in obesity =>arrhythmia =>sudden deathIn selected patients:EchoStress tests
7. Venous thromboembolism (VTE) & pulmonary emboli (PE)Second cause of death after leak in bariatric surgeryIn 0.2 to 3.5 %High risk patients:MaleHigh BMIop time>3hhypercoagulable stateVery high risk patients:BMI>55OHS
8. Venous thromboembolism & pulmonary emboliReducing the riskIncreasing ambulationSmoking cessationW reductionPreventionThromboembolism deterrent hose (TED)IPCDAnticoagulant( heparin or LMWH)IVC filter: not recommended
9. Cardiologist consult
10. Pulmonary statusObesity:ReducedChest wallLung complianceGas exchangeIncreasedV/P mismatchAirway resistanceWork of breathing
11. Pulmonary statusSleep apneaHOSAsthmaCOPDDyspnea by walking less than 200f)
12. Obstructive sleep apneaIn 88% of candidates for bariatric surgMechanism: stenosis & obs of airways in sleep=>sleep hypoxia=>arrhythmia & pul HTNNarcotic & anesthetic drugs =>severe hypoxia & respiratory arrest Symptom:Ioud snoring/tiredness on walking/sleep during driving or sittingDX: polysomnography (PSG) routin or selectiveTx:Continuous positive airway pressure(CPAP) before & after surg
13. Obesity hypoventilation syndromeOHSSevere pul dysfunction: co2 retention=>hypersomnolence=>co2 narcosis & arrest=>=>need to ICUSevere hyoxia during sleepingSymp:Severe dyspneaexcessive day time sleepinessDx: BMI>30/ Pco2>45 without res or neuromuscular dis/po2<55/polycytemiaScreening:Day time pulse oxymetry <94%Serum bicarbonate >27ABG if above tests are abnormal: pco2>45/po2<70
14. Pulmonary function testFor Dx of COPDFor oxygen users at home
15. Pulmonary specialist consult
16. GI evaluationSymptomatic patientEGD(preferred) or UGI (barret es/lesion of UGI/ hiatal hernia/ HP)Non symptomatic:LAGB & sleeve:Nothiong orUGI for hiatal hernia & esophageal dismotilityRYGB & BPD & DS:Routin UGI or EGDRevisional op:EGD &/or UGIColon cancer screeningHP screeningFor high prevalence areasBy stool Antigen & UBTTx especially before RYGB & MGB
17. Psychological evaluationInterviewForm filling test: rarelySelective evaluation is recommendedContraindications:Active drug usersSchizophreniaNot understanding the risk & benefit of surg medication after operation
18. Ultrasonography Abdominopelvic USLiver sizeGallstoneCholecystectomy at the same operation or after weight loss (controversy)
19. LAB tests CBC/diff/FBS/Hb A1c/BUN/CREAT/Uric Acid/TG/Cholestrol/HDL/LDLAlb/Prot/SGOT/SGPT/LDH/ALKPh/Bili DR&TOTAL/PT/PTT/INRT3/T4/TSH/PTH/CORTISOLNa/K/Ca/Ph/Iron/Ferritin/TIBC/Vit D3/Zinc/Vit B12HBS Ag & Ab/HCV/HIVBHCG/BG & RhU/A
20. Inform consent
21. SUMMERYConsult:CardiologistPulmonologistPsychiatristDietitianSport specialistEndocrinologist if needGI evaluationLAB TestsUSMammography & pap smear??Inform consent
22. Thank You