Multiple Choice Questions on Weightloss and bariatric surgery.
Q1. Dietary restriction is the 1st step in initiating weight loss in patients with
Morbid Obesity. Which of the following is not true regarding diet control in such patients
a) Patients with Body mass index (BMI) more than 35% an energy restriction of 1000 cal/day
induces weight loss of 1 pound/day
b) Adherence to low calorie diet reduces weight loss of about 6-8% in 6 months
c) Energy deficit leads to glucogen mobilization
d) Water loss also occurs in this state
Q2 Which of the following weight loss surgery for morbid obesity is obsolete
a) Gastric Bypass
b) Jejuno ileal bypass
c) Vertical band gastroplasty
d) Bilio Pancreatic Diversion
Q3. Most Effective therapy for morbid obesity, in terms of weight loss is:
a) Intensive dieting with behavior modification.
b) A multidrug protocol with fenfluramine, phenylpropanolamine, and mazindol.
c) A gastric bypass with a 40-ml. pouch, a 10- to 20-cm. Roux-en-Y gastroenterostomy.
d) A gastric bypass with a 15-ml. pouch, a 40- to 60-cm. Roux-en-Y gastroenterostomy.
Q4. False about gastric bypass surgery for weight loss is
a) In gastric bypass surgery there is progressive weight loss upto 3 yrs
b) Horizontal gastroplasty with the application of single
horizontal stapler has a failure rate of 40-70%
c) Gastric bypass surgery has a failure rate of about 15% in terms of weight loss
d) With three superimposed applications of a stapling device,
gastric bypass staple line dehiscence occurs in less than 2%
Q5. Jejunoileal bypass surgery has now been abandoned.
Which of the following is true following jejunoileal bypass?
a) Kidney stones occur with increased frequency due to
increased absorption of pyruvate from the colon
b) The most serious complication of jejunoileal bypass is development
of cirrhosis due to protein calorie malnutrition
c) Bacterial overgrowth in the bypassed segment can be treated with oral vancomycin
Q6. Which of the following statements is correct with regard to gastric bypass for obesity?
a) Rapid weight loss following successful gastric bypass
for obesity is associated with an increased risk of developing cholelithiasis
b) Marginal ulcer develops in 25% of gastric bypass patients
c) Vitamin B12 deficiency is a potential complication of
gastric bypass due to gastric mucosal atrophy
d) Anastomotic leak after gastric bypass surgery (weight loss procedure) is often heralded by bradycardia
Q7) False regarding Bariatric surgerya) VBG produces less weight loss when compared to RYGB
b) Jejuno-ileal by-pass not done nowadays
c) Dumping is due to non- compliance of dietary advice
d) LAGB requires once a 4-6wk follow up
Answer to 7
Answers Weight loss surgery
Any patient of morbid obesity when seen for the 1st time should be advised life style
modification as well as dietary restrictions. Low calorie diet is one such option but it requires
adherence and determination.
Low calorie diet of about 1000 cal /day leads to weight loss of 1 pound in a week and not in one day
All other statement are true
Ref- Buchwald: Surgical Management of Obesity, 1st ed.
Earlier jejunoileal bypass was the procedure done for morbid obesity. Later results showed that this procedure was associated with significant short term and long term complications, the most important being cirrhosis due to bacterial overgrowth and malabsorbtion.
Biliopancreatic diversion involves the diversion of these secretions to the bypassed intestinal segment. This procedure decreases but does not completely eliminate bacterial overgrowth.
Shackelford stomach pg 194.
In all weight loss surgery procedures-
Gastric bypass procedure is the procedure of choice whenever possible.
Three to Four super imposed staples are placed vertically to create a small
gastric pouch 15-30ml. The proximal pouch is anastomosed to roux en y
limb 60-75 cm long.
Schakelford stomach pg 195
Weight loss surgery has several options-
Horizontal gastroplasties include a single application of a 90-mm
stapling device without suture reinforcement of the “stoma’’ between
upper and lower gastric pouches or a double application of staples with
either a central or lateral prolene-reinforced stoma. The failure rates
for horizontal gastroplasty procedures ranges from 40% to 70%.
The vertical banded gastroplasty (VBGP) is a procedure in which
a stapled opening is made in the stomach with the stapling device
5 cm from the cardioesophageal junction. Two applications of a
90-mm stapling device are made between this opening and the angle of His,
and a 1.5 5 cm strip of polypropylene mesh is wrapped around the stoma on the
lesser curvature and sutured to itself.
Gastric bypass can be performed with placement of staples in a vertical
or horizontal direction; the vertical direction is preferred because there is less
risk of gastric pouch devascularization or splenic injury. With three superimposed
applications of a 90-mm stapler, the incidence of staple line disruption has been
less than 2%.
Roux-en-Y gastric bypass has significantly better weight loss than VBGP.
Although 10% to 15% of patients fail gastric bypass, weight loss seems to remain
stable in most patients over 5 years or more after surgery.
Weight loss after GBP(Gastric Bypass Procedure) occurs over 1-3 years
Ref. Schakelford stomach 197.
Malabsorption of bile salts, coupled with rapid weight loss after bariatric surgery
significantly increases risk of gallstone development. Multiple kidney stones
result from excessive absorption of oxylate from the colon where oxylate
is ordinarily chelated with calcium. Malabsorption results in severe
diarrhea, electrolyte abnormalities, metabolic acidosis and anemia.
Bacterial overgrowth in the bypassed intestinal segment coupled with
protein malabsorption is postulated to be responsible for development
of cirrhosis, the most serious complication of jejunoileal bypass.
Bacterial overgrowth can be temporarily suppressed by metronidazole.
Development of hepatic dysfunction is an indication for reversal of the bypass.
Ref. Shackelford stomach 197.
Anastomotic leak after weight loss surgery is accompanied with tachycardia not bradycardia.
Signs of peritonitis following such surgical procedures with anastomotic leak are subtle.Marginal Ulcer
develops in 10%. Vit B12 deficiency occurs due to decreased acid digestion of B12 with
Calorie restriction is responsible for long term weight loss and its beneficial effects such as control of diabetes, dyslipidemia, hypertension and other metabolic abnormalities.
Restrictive procedures are LSG and LAGB which decrease the appetite and induce early satiety.
The RYGB (ROUX en Y gastric bypass ) is a malabsorptive procedure with long term sustained weight loss.
Mechanism of weight loss after bariatric surgery
Ghrelin is orexigenic gut hormone, which increases appetite. After food intake ghrelin levels fall and appetite decreases.
After restrictive surgery such as LYGB and LSG, ghrelin levels fall and appetite decreases.
Vertical Banded Gastroplasty (VBG) This procedure has been abandoned in favor of other operations because of poor long-term weight loss, a high rate of late stenosis of the gastric outlet, and a tendency for patients to adopt a highcalorie liquid diet, thereby leading to regain of weight. Choice a is correct
Jejuno ileal bypass has many side effects because of malabsorbtion and liver cirrhosis ( See above) . Choice b is true
Visit - evaluate oral intake, food tolerance, and wound healing and to determine whether appropriate restriction has resulted from placement of the non inflated band.
Subsequent visits, usually scheduled monthly to bimonthly in the beginning and then less frequently, involve counseling with a nutritionist and evaluation of weight loss and the need for band adjustment.
A goal of 1 to 2 lb/wk is ideal d is correct
Dumping is both late and early and unrelated to dietary advise
Sabiston page 1180-83