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Patients 6 Indications and Contraindications for Bariatric Surgery 75 Psychiatric Illness A diagnosis of psychopathology depression test deutsch order bupropion master card, including eating disorders neonatal depression definition order discount bupropion on line, does not preclude metabolic and bariatric surgery [7] depression definition government generic bupropion 150 mg online. Successful outcomes have been demonstrated in patients with major depressive disorder, bipolar disorder, stable schizophrenia, and binge eating. Patients with active psychosis or recent hospitalization for psychosis, as well as patients with suicidal ideation or recent suicidal attempts, should have surgery delayed or postponed and treatment initiated. Ongoing therapy for these patients is essential in the postoperative period if deemed stable and cleared for surgery. Nonambulators Nonambulatory status is considered a contraindication to bariatric surgery by some programs. Although nonambulatory status and poor functional capacity has been demonstrated to increase perioperative morbidity and reduce postoperative weight loss, this increased risk does not exceed the potential benefit in properly selected, motivated patients. Cirrhosis Nonalcoholic fatty liver disease is common in severe obesity, with histologic evidence of steatosis present in nearly 90 % of patients undergoing metabolic and bariatric surgery and unexpected cirrhosis identified in 2 % of patients [9]. Weight loss following surgery has been demonstrated to improve the histologic findings of steatosis and steatohepatitis. When cirrhosis is an incidental finding at surgery, it is recommended to proceed in the absence of findings of significant portal hypertension including severe ascites and perigastric varices. If evidence of portal hypertension is encountered unexpectedly, the procedure should be aborted. Bariatric surgery has been reported in highly selected patients with advanced cirrhosis in preparation for liver transplantation. Reported cases are few and should only be performed in tertiary centers in partnership with a liver transplant service. Conclusion Metabolic and bariatric surgery produces durable weight loss well beyond that achieved with medical and behavioral therapies, with resultant improvement in obesity-related comorbidities and quality of life. Appropriate patient selection is mandatory to ensure optimal results while minimizing perioperative risks. The following should all be considered contraindications for bariatric surgery except: A. Limited life expectancy due to irreversible cardiopulmonary disease or inoperable malignancy C. Inability to comprehend the risks and benefits of the planned procedure and comply with postoperative lifestyle and dietary modifications and follow-up D. Which of the following psychiatric conditions is a contraindication for bariatric surgery Modern antiretroviral therapies have dramatically reduced disease progression, extending life expectancy, often with nearly undetectable viral loads. Suggestions for the pre-surgical psychological assessment of bariatric surgery candidates. Current psychological assessment practices in obesity surgery programs: what to assess and why. Initial experience with bariatric surgery in asymptomatic human immunodeficiency virus-infected patients. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient-2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery. Regardless of whether a specific evaluation in question is subjective or objective, it should be standardized in an evidence-based protocol. This chapter will describe evidence-based comprehensive preoperative evaluation of the bariatric patient, discuss risk assessment to optimize patient selection and informed consent, and explain establishment of preoperative pathways. Patient Selection Introduction Preoperative care of the bariatric patient starts before the patient arrives. Establishment of data-driven patient selection protocols and preoperative evaluation pathways not only streamline practice, but also improve patient safety. Both evaluation and individualized risk assessment are essential for achieving best outcomes and allowing the patient to give a truly informed consent. Certainly, a significant outcomes shift in bariatric surgery can be made by optimizing preoperative selection of patients.

As the close interaction between diet mood disorder evaluation buy generic bupropion 150mg line, gut depression test dr oz cheap bupropion master card, and brain hormones become known depression test free online nhs buy bupropion 150 mg amex, the mechanisms of action of these procedures, as well as their classification, have significantly changed. In fact, it has now become well recognized how the centrally regulated body weight homeostasis is profoundly influenced by hormones secreted in the intestinal tract and adipose tissue [4]. The overall balance of these peripherally secreted hormones and their interaction at the level of the hypothalamus would eventually affect food intake and energy expenditure [5]. The mechanism of diabetes resolution after bariatric surgery is not entirely understood. Since insulin resistance is one of the main etiologies, it seems obvious that weight loss is an important one but not the only of the factors involved in remission of metabolic syndrome. In fact, typically diabetes improvement or resolution occurs within weeks after bariatric procedures. We here describe some of the most commonly accepted theories regarding the mechanism of action of the most widely accepted bariatric procedures. Mechanism of Action the current understanding of different mechanisms of action of these procedures, in particular the role of gut hormones, has led to dispute the traditional classification of the bariatric procedures in the three main categories: restrictive, malabsorptive, and combined. Although a clear understanding of all the mechanisms of action of the bariatric procedures has not been reached, multiple theories exist. It is likely that several factors contribute to the final efficacy of the procedures. Because of the overlap of effects, we will address the potential mechanisms of action affecting both weight loss and diabetes resolution. Malabsorption As previously mentioned, the surgically induced alterations of the normal gastrointestinal absorption process lead to various degrees of weight loss. This factor undoubtedly contributes to the immediate weight loss experienced by these patients postoperatively. Also if the caloric restriction was the only responsible mechanism for glucose control, the improvement of this parameter should be uniform between the different bariatric operations. It is reasonable to conclude that, although caloric restriction is an important factor contributing to the improvement in hepatic insulin sensitivity, it likely plays a role only in the immediate postoperative period and other factors are involved in the long-term weight loss and glycemic control improvement. Energy Expenditure Under normal circumstances the energy expenditure decreases consequently to caloric restriction and the resulting weight loss [19]. This adaptive mechanism on one hand is meant to preserve the individual and on the other hand could be responsible in part for the long-term failure of the caloric restrictive diets. No definite conclusions on the role of energy expenditure can be drawn at this time, and additional mechanisms should be sought to explain the metabolic improvements after bariatric surgery. Entero-hormones the ingestion of food determines alterations of the gastrointestinal, endocrine, and pancreatic secretions, known as the enteroinsular axis. Changes in Eating Behavior the consumption of diets high in fat has been associated with the development and maintenance of obesity in both humans and rodents [23, 24]. Also obese individuals have a greater propensity to choose high fat foods, as compared to lean ones [25]. On the other hand, it is known how the eating behaviors change after bariatric surgery. These findings cannot only be explained by the mechanical restriction, as a compensatory choice of more caloriedense foods to maximize caloric intake would have occurred. Other options to explain such behaviors include postoperative changes of the taste acuity and neural responses to food cues. Other possible mechanisms include the aversive symptoms proper of some of the bariatric operations derived by improper food choices. In particular, the development of the uncomfortable symptoms of the dumping syndrome might steer patients away from high caloric carbohydrates.

The stomach wall will frequently be thickened compared to fresh tissue depression essential oils cheap bupropion amex, so choosing staplers with a longer closed staple height may reduce the risk of staple line leakage mood disorders kaplan ppt discount bupropion 150 mg with amex. Lastly depression rates buy bupropion toronto, any gastric injuries made during the band removal should be repaired or resected. We do recommend the repair of any hiatal hernias identified during band removal but favor doing this after leak testing of the gastrojejunostomy, as crural repair may impair the passage of orogastric tubes. Postoperative care is similar to that of patients undergoing gastric bypass as a primary procedure. In view of the higher risk of anastomotic leak and serious complications, we recommend that experienced surgeons perform these procedures. We frequently perform postoperative contrast esophagograms prior to introducing oral intake in revisional procedures. One Stage Versus Two Stages the aforementioned description of surgery is for a singlestage revision of adjustable gastric band to gastric bypass. An alternative to band removal and gastric bypass during one operation is to first remove the band, and then after several weeks or months of healing, perform the gastric bypass during a second operation. The first operation to remove the band proceeds according to the previous description as far as removing the band, dividing adhesions, and taking down the gastrogastric plication. An adhesion barrier can then be placed beneath the left lateral section of the liver to facilitate dissection during the next operation. Hiatal hernias may be repaired, the access port is removed, and the operation is terminated at this point. Gastric bypass is performed at a later date, after the patient has recovered from the band removal surgery. The rationale behind performing a revision operation in two stages is to reduce the complication rate of revision surgery. Of these, 13 underwent a one-stage revision to Roux-en-Y gastric bypass, and the remaining 7 had this performed as a two-stage procedure with a delay of between 4 and 84 months between the two operations. They noted twice as many early complications in the group undergoing one-stage revision (31 % vs. Another retrospective study from Belgium [12] compared the outcomes of 23 patients undergoing one-stage revision from adjustable gastric banding to Roux-en-Y gastric bypass with those of 14 patients undergoing two-stage revision with a minimum delay of 2 months. These authors found that total length of operating time was longer in patients undergoing two-stage revision (181 vs. However, they also observed fewer early complications in those patients undergoing revision in two stages (0 vs. We note that although large differences were observed in complication rates in both of these studies, 25 Reoperative Options After Gastric Banding 287 neither reached statistical significance. Revision bariatric surgery remains relatively uncommon as do post-op complications, making it difficult for any one center to accrue sufficient patients to conduct these studies with adequate statistical power. We also were unable to identify any randomized studies comparing onestage to two-stage revision surgery. Mini, Distal, and Open Variations on revision to laparoscopic Roux-en-Y gastric bypass include the "mini" or loop gastric bypass, a distal or malabsorptive gastric bypass, and an open gastric bypass. Rutledge, a proponent of the "mini" gastric bypass, where a loop gastrojejunostomy is created in place of a Roux-en-Y reconstruction, describes the outcomes of three patients undergoing this procedure as a revision from adjustable gastric banding [13]. He reports a mean operating time of 54 min, with no conversions to laparotomy (compared to 37. Another variation on the typical "proximal" Roux-en-Y is the "distal" or malabsorptive Roux-en-Y gastric bypass. In this variation, the gastric bypass is constructed with a relatively short common channel to increase energy malabsorption, and consequently weight loss. Their series had no postoperative mortalities and no major postoperative complications. No patients in this series required lengthening of the common channel for nutritional complications.

Fortunately postpartum depression definition who 150 mg bupropion visa, with growing research showing the complexity of energy regulation and balance anxiety girl buy bupropion 150 mg visa, this formerly pervasive attitude has subsided depression ted talk buy discount bupropion 150mg line. Obesity needs to be treated both aggressively and chronically in order for patients to not only lose the weight, but to help them A. The development of drugs for the treatment of obesity has historically been wrought with challenges. Some of the first medications used for the treatment of obesity included thyroid extract and subsequently dinitrophenol; however, both were discontinued due to serious side effects. In the 1930s, Benzedrine and amphetamines were introduced and their use increased over subsequent decades. In 1959, phentermine was approved for the treatment of obesity, and subsequently in 1973, it was combined with fenfluramine [3]. This combination, otherwise known as "fen-phen," was linked to both cardiac valvulopathy and pulmonary hypertension, and fenfluramine and its isomer, dexfenfluramine (Redux), were removed from the market in 1997. Phentermine alone was not deemed on its own to be a factor in cardiac valvulopathy, and it remained on the market. The road for obesity treatment only became further challenged by the approval and subsequent removal of sibutramine, an anorectic agent used to control appetite. In order for a new weight loss drug to be considered effective, at least one of the following must be true after 1 year of treatment: the difference in mean weight loss between the active-product and placebo-treated groups is at least 5 % and is statistically significant or the proportion of subjects who lose greater than or equal to 5 % 157 C. Apovian of baseline body weight in the active-product group is at least 35 %, is approximately double the proportion in the placebo-treated group, and is statistically significant [5]. Until recently, there were only two classes of drugs approved for the treatment of obesity: pancreatic and gastric lipase inhibitors including orlistat and sympathomimetic agents, including phentermine. Goals of Pharmacotherapy the first step prior to initiating treatment should be to set up a realistic weight loss goal and discuss this with the patient. Further, it is well understood that once a drug is discontinued, the patient will likely regain the weight they have lost while on drug therapy. While there is no long-term data (>2 years) for many of the weight loss medications, a discussion should be made with the patient as to whether or not to continue treatment in order to maintain the weight lost. As with all other chronic medical conditions, obesity will require lifelong treatment in order to prevent weight regain. Indications for Pharmacotherapy Diet, exercise, and behavior modification should be the foundation of all treatments for obesity. However, pharmacological therapy can and should be used in the correct patient as an adjunctive treatment once a careful evaluation has been completed. Weight-Promoting Medications In addition to initiating pharmacotherapy, the medical approach to treating obesity should include the avoidance of weight-promoting medications and optimizing treatment with weight-neutral alternatives. As discussed, overweight and obese patients suffer from a number of comorbid medical conditions including depression, cardiovascular disease, and diabetes, which are often treated with medications that may promote weight gain. There are often weight-neutral medications available and should be considered whenever possible (Table 16. This medication is best prescribed with patients who are able Contraindications for Pharmacotherapy While each drug discussed in this chapter will have specific contraindications for use, the general contraindications include: pregnancy, breastfeeding, unstable cardiac disease, unstable severe systemic illness, history of anorexia nervosa, active severe psychiatric disorder, and/or drug-drug interactions. If a patient is taking levothyroxine, he or she should be advised to separate these medications by 4 h. Ziprasidone, aripiprazole Phentermine/Diethylpropion (Also Known As Adipex, Fastin, Ionamin) Phentermine stimulates the release of norepinephrine, which leads to early satiety and reduced food intake. In the longest study of 36 weeks of continuous treatment, subjects receiving phentermine 30 mg lost 12. This medication should be used for patients who have difficulty controlling their appetite and only be used in conjunction with a structured diet and exercise program. The most common adverse effects include xerostomia, insomnia, headache, overstimulation, palpitations, and constipation. In order to minimize the side effects, a patient should be treated with the lowest dose, and it can be titrated up if the patient tolerates it. Patients with uncontrolled hypertension should not use this medication, and all patients should be monitored closely for elevations in their blood pressure and heart rate.

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