Aftercare Following Weight Loss Surgery

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Aftercare Following Weight Loss Surgery

• Gray N. Dawson, MD, FAAFP
• Lieutenant Commander, Medical Corps, U.S. Navy
• Officer in Charge / Senior Medical Officer
• U.S. Navy Branch Health Clinic St. Mawgan UK

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Plan of the Day

• Why bother
• Procedures
• Complications
• Recommendations
• EBM Problems
• Scenario Revisited

3
Why Bother?

• Patient has already had surgery not addressing
  recommendations for or against bariatric surgery
• Scenario
• Busy family medicine clinic
• 49 y/o female pt on schedule for F/u labs
• CC I just moved to the area and need my
  six-month f/u appt following gastric bypass
• Questions
• What labs do I need to order?
• What complications should I be looking for?
• What is a realistic goal for the patient?

4
What you likely already know about Bariatric
Surgery

• Better weight loss than diet and exercise
• Decrease disease burden
• DM, HTN, lipids, CAD, arthritis, sleep apnea,
  fatty liver, metabolic syndrome, GERD PCOS
• Generally safe, but with many complications and
  consequences (change lifestyle)
• Recommended for (by NIH consensus 1991)
• Refractory obesity (BMI gt35) with disease burden
• Morbid obesity (BMI gt40)
• Covered by Tricare
• To be covered, you must be 100 pounds over
  ideal body weight and have a co-morbidity or 200
  percent of ideal body weight with no
  co-morbidity https//www.triwest.com/triwest/defa
  ult.html?/triwest/unauth/content/provider/handbook
  /provider/imp_tricare_policy.html

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What you may not know about bariatric surgery

• Elderly covered by Medicare, little study on
  this age population
• Pediatrics 1000 cases done in 2003 and
  increasing
• Risks are highly variable depending greatly on
  experience / skill of surgeon
• Death rate approx 1.5-1.9
• Complications up to 70 in studies

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Procedures

• Three types of procedures
• Malabsorptive (reduce calorie absorption)
• Biliopancreatic diversion (/- duodenal switch)
• Restrictive (reduce volume)
• Vertical gastric banding
• Laparoscopic adjustable gastric banding
• Gastric bypass (both)
• Roux-en-Y (laparoscopic / open)
• Choice of procedure depends on patient, health
  status, surgeon (experience)
• Malabsorptive procedure (BPD) recommended for
  severe morbid obesity (BMI gt50)

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Short term complications

• Venous thromboembolism
• Wound infection (greater with open procedures)
• GI leaks (greater with laparoscopic and low
  experience)
• Bleeding
• Incisional hernia
• Stomal stenosis (vomiting / intolerance to food
  and fluids)
• Marginal ulceration (hematemesis / melena avoid
  NSAIDs)
• Constipation (pain meds, poor fluids,
  malabsorption avoid granular bulking agents)

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Complications Vomiting

• Early related to dietary factors such as poor
  chewing or too much intake
• Mid (3-6 months) same, also consider thiamine
  deficiency
• Late (gt6 months) same, plus consider stomal
  stenosis

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Complications Dumping Syndrome

• Related to intake of high sugar foods/fluids
• Undigested CHO causes rapid fluid influx in
  jejunum causing procholinergic symptoms
• Diarrhea / crampy abdominal pain
• Nausea
• Lightheadedness
• Palpatations / sweating
• Generally avoidable with dietary modification,
  not seen as much with complex natural sugars
  (fruits / vegetables)

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Complications Gallstones

• Frequent complication, generally GB removed at
  time of bariatric surgery if gallstones present
  prior to surgery surgery
• If not removed, ursodeoxycholic acid prescribed
  up to six months poor evidence for use
• Surgery is best treatment if symptoms develop
• Tricare and many other insurers do not cover
  removing prophylactically without symptoms

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Complications Drug Absorption

• Change in gastric pH
• Change in volume of distribution with weight loss
• Change in intestinal surface area
• Need to monitor effects from medications,
  especially thyroid, psychiatric, epilepsy, DM,
  and HTN meds

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Complications Nutritional Deficiency

• Most commonly associated with malabsorptive
  procedures and include the following
• Iron
• Calcium
• Vitamin D
• Vitamin B12
• Fat Soluble Vitamins
• Protein
• Thiamine
• Folate

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Nutritional Recommendations

• MVI or PNV with Iron
• May need additional supplemental iron up to
  40-60mg/day elemental
• B12 (100-300mcg/day higher if deficient)
• May need monthly 1mg injections
• Calcium w/ Vit D (1200mg/day 400IU/day)
• Recommended calcium citrate vs. carbonate since
  low pH is required for CaCO3
• Some suggest up to 1500mg/day calcium and 1000IU
  Vitamin D to prevent bone mineral density loss
• High protein diet (lean protein)

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Screening Recommendations

• First Year
• q3 months CBC, Glu, Cr
• q6 months LFT (w/ protein, albumin), Ferritin,
  TIBC, B12, Folate, Ca
• PTH (if Ca elevated or to ensure Ca stable)
• Vit D (possibly to ensure adequate Ca)
• Every year thereafter
• All of the above
• Postmenopausal women BMD Screening
• Variable recommendations, probably worth
  screening and ensuring maximum calcium / vit D tx
  if low BMD

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Family Planning Recommendations

• No pregnancy for female patients for 18 months
• Contraception needs may change with weight loss
• Pregnancy even later can be problematic and may
  need more frequent screening or more aggressive
  preventive treatments
• B12, Folate, Iron

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Show me the evidence

• Retrospective / case series / cohort
• Very few good RCTs
• Does it improve long-term survival?
• Flum (2004) Mortality at 15 years, N3,328
• Operated 11.8
• Non-operated 16.3
• Does it improve long-term QOL?
• Difficult to measure, no good studies
• Still many good long term retrospective / cohort
  studies

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Evidence

• Bariatric surgery leads to sustainable weight
  loss and may reduce weight related co-morbidities
  (SORA)
• Prophylaxis to prevent VTE (DVT / PE)
  postoperatively using LMW heparin is indicated in
  nearly all patients (SORA)
• Other recommendations based on incidence of
  disease and/or expert opinion such as pregnancy
  recommendations, screening recommendations, and
  nutritional supplementation (SORB/C)
• See www.aafp.org/afpsort.xml for more info on SORT

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Scenario Revisited

• What do I need to order
• CBC, iron studies, LFT (albumin / protein), Ca,
  Glu, Cr, B12, Folate (expert opinion)
• Some suggest PTH/VitD, BMD scan yearly
• PNV, Ca w/ Vit D, Iron, B12, Folate
• What complications should I be looking for
• No longer menstruating (no contraceptives)
• Nutritional deficiencies, esp. iron, B12,
  protein, calcium
• Gallstone dz or post-surgery complications
• Psychologic impacts of lifestyle changes
• What is a realistic goal
• Weight loss of approximately 35-70 of excess or
  sustained 45-65 lbs at 10 years (avg.)

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For More Information

• Viriji A, Murr MM. Care for Patients After
  Bariatric Surgery. Am Fam Phys 2006731403-8.
• http//www.aafp.org/afp/20060415/1403.html
• Good general overview
• Stendardo, S, Kushner PR. Caring for Patients
  After Bariatric Surgery. CME Bulletin (AAFP)
  20065(2)1-6.
• http//www.aafp.org/online/etc/medialib/aafp_org/d
  ocuments/cme/selfstudy/bulletins/bariatricbulletin
  .Par.0001.File.dat/cmebulletin_bariatric.pdf
• Good general overview
• Mason ME, Jalagani H, Vinik AI. Metabolic
  Complications of Bariatric Surgery Diagnostic
  and Management Issues. Gastroenterol Clin N Amer
  20053425-33.
• Review of metabolic problems for follow-up
• F. Safadi, Trends in Insurance Coverage and
  Impact of Evidence Based Reviews, Surg Clin N
  Amer 200585665-680.
• Great EBM Review
• Brechner RJ, Farris C, Harrison S, Tillman K,
  Salive M, Phurrough S. Summary of Evidence
  Bariatric Surgery, Center for Medicare Studies,
  November 4, 2004, retrieved from
• http//www.cms.hhs.gov/FACA/downloads/id137c.pdf
• Great EBM Review

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Further Bibliography

• Ali MR, Fuller WD, Choi MP, Wolfe BM. Bariatric
  Surgical Outcomes. Surg Clin N Am
  200585835-852.
• Li Z, Bowerman S, Heber D. Health Ramifications
  of the Obesity Epidemic. Surg Clin N Am
  200585681-701.
• Livingston EH. Complications of Bariatric
  Surgery. Surg Clin N Am 200585853-868.
• Neligan PJ, Williams N. Nonsurgical and Surgical
  Treatment of Obesity. Anesthesiology Clin N Amer
  200523501-523.
• Puzziferri N. Psychologic Issues in Bariatric
  Surgery the Surgeons Perspective. Surg Clin N
  Am 200585741-755.
• Stumbo P, Hemingway D, Haynes WG. Dietary and
  Medical Therapy of Obesity. Surg Clin N Am
  200585703-724.
• Xanthakos SA, Daniels SR, Inge TH. Bariatric
  Surgery in Adolescents An Update. Adolesc Med
  200617589-612.