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Q31 Which of the following surgical treatments for morbid obesity is obsolete

a) Gastric Bypass

b) Jejuno ileal bypass

c) Vertical band gastroplasty

d) Bilio Pancreatic Diversion

Q32. Effective therapy for morbid obesity, in terms of weight control 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.

Q33. False about gastric bypass surgery 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 bypasssurgery has a failure rate of about 15%

d) With three superimposed applications of a stapling device,

gastric bypass staple line dehiscence occurs in less than 2%

Q34. 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

 d)

Q35. 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) Anastamotic leak after gastric bypass is often heralded by bradycardia

Answers
31. b

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.

Schakelford stomach pg 194.

32) d

Gastric bypass procedure is the procedure of choice whenever possible.

Three to Four supeimposed 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

33)a

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.

34) c

 Malabsorption of bile salts, coupled with rapid weight loss

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. Schakelford stomach 197.

35)a

Anastomotic leak is accompanied with tachycardia not bradycardia.

Signs of peritonitis following anastomotic leak are subtle.Marginal Ulcer

develops in 10%. Vit B12 deficiency occurs due to decreased acid digestion of B12 with

food.