SOAP. – Post–Bariatric Surgery Long-Term Follow-Up

Kathy R. Reese and Cheryl A. Glass

Definition

A.The number of obese people in the United States has more than doubled in the past 50 years. The traditional management of obesity, a combination of diet, exercise, and behavioral modification, often results in moderate success with limited sustainability. Increasing prevalence of obesity combined with improvements in surgical weight-loss procedures and improved insurance coverage has resulted in exponential growth of the number of people opting for surgical management. Patients who undergo surgical weight-loss procedures have unique healthcare needs and require lifelong follow-up. Although the bariatric treatment team is the ideal source of follow-up and monitoring, primary care providers can play a critical role and need to be cognizant of the unique needs of this population.

B.The primary mechanism of action for surgical weight-loss procedures is either restriction or a combination of restriction and malabsorption (see Table 14.24). All procedures have some form of restriction that reduces the volume of food that can be ingested. Restriction can occur by means of a physical barrier such as a laparoscopic adjustable gastric band (LAGB; see Figure 14.4), or an intragastric balloon (see Figure 14.7) or by removing a portion of the digestive tract such as with the gastric sleeve (GS; see Figure 14.5). Malabsorptive procedures cause weight loss by changing the way nutrients are absorbed, which is accomplished by removing portions of the stomach and/or small intestine and sometimes by rerouting the digestive tract (Roux-en-Y; see Figure 14.6). The success of surgical weight loss is defined by initial weight loss, maintenance of weight loss, and prevention of complications. Success is directly related to the aftercare a person receives.

Incidence

A.According to the 2015–2016 National Health and Nutrition Examination Survey (NHANES), the prevalence of obesity is 39.8%; among adults aged 40 to 59 years, the prevalence is higher (42.8%)-. The American Society for Metabolic and Bariatric Surgery (ASMBS) reports an estimated 228,000 weight-loss operations were performed in 2017. About 90% of surgical weight-loss procedures are performed laparoscopically now. The most common procedures performed today include the gastric bypass, gastric sleeve, adjustable gastric band, and biliopancreatic diversion with duodenal switch. The intragastric balloons were U.S. Food and Drug Administration (FDA) approved in 2015; only about 2.75% were done in 2017. The intragastric balloon is a temporary weight loss procedure with placement only for 6 months.

Pathogenesis

A.The pathogenesis of obesity is reviewed under Obesity. Significant improvements in the safety of surgical weight-loss procedures in recent years result from improved surgical techniques, accreditation, and the use of laparoscopy. The overall mortality rate is about 0.5%. The incidences of complications vary by surgical procedure. Postoperative complications may occur immediately or may occur many years after surgery. Nutritional deficiencies are by far the most common long-term complication.

FIGURE 14.4Laparoscopic adjustable gastric band (LAGB).

FIGURE 14.5Sleeve bypass procedure with stomach resection.

Predisposing Factors

A.Higher body mass index (BMI).

B.Noncompliance with bariatric diet and exercise.

C.Lack of follow-up with healthcare professionals.

D.Obesity-related health problems:

1.Sleep apnea.

2.Diabetes.

3.Arthritis.

4.Hypertension.

5.Gastroesophageal reflux disease (GERD).

E.Complexity and type of surgery.

Common Complaints

Functional and Nutritional

A.Dumping syndrome usually occurs within 30 minutes of eating high-fat/high-sugar foods and involves flushing, sweating, lightheadedness, tachycardia, palpitations, nausea, diarrhea, cramping.

B.Hypoglycemia occurs 1 to 3 hours after eating high-carb meals and involves shakiness, anxiety, sweating, chills, clamminess, confusion, rapid heart rate, dizziness, hunger, and nausea.

C.New or exacerbated reflux is more common with a gastric sleeve.

D.Vitamin deficiencies or toxicities (refer Table 14.25):

1.Most common:

a.Iron deficiency—Fatigue, lethargy, pica, food cravings.

b.Iron toxicity—Gastrointestinal irritation, nausea, vomiting, indigestion, constipation, diarrhea.

c.Protein deficiency—Weakness, decreased muscle mass, brittle hair, generalized edema.

d.Folate deficiency—Fatigue, palpitations, sore tongue, diarrhea, restless legs.

e.Calcium deficiency—Usually silent, hyperparathyroidism.

f.Calcium toxicity—Constipation, nausea, vomiting, dry mouth, loss of appetite.

g.Vitamin D deficiency—Spasms/twitching of eyes, burning in mouth, sweating, weakness.

FIGURE 14.6Roux-en-Y gastric bypass (RYGB).

h.Vitamin B12 deficiency—Fatigue, burning lips/-mouth, rapid heart rate, palpitations, sore tongue, weakness, mood changes, neurologic changes.

2.Less common:

a.Thiamine (B1) deficiency—Usually in first 3 months postop, often a result of vomiting, blurred or double vision, difficulty swallowing, rapid heart rate, fatigue, confusion, memory loss, burning feet, leg weakness, amnesia.

b.Zinc deficiency—Loss of smell, diminished sense of taste, poor wound healing, skin rashes or roughness, hair loss, poor appetite, lethargy, grooved or deformed nails, canker sores.

c.Magnesium deficiency—Hyperexcitability, cramps, tremors, fasciculation, spasms, fatigue, loss of appetite, apathy, confusion, insomnia, irritability, poor memory.

d.Selenium deficiency (very rare)—Signs of hypothyroidism (selenium is necessary for conversion of thyroxine into its active form, triiodothyronine).

FIGURE 14.7Intragastric balloon

e.Selenium toxicity (rare)—Hair loss, abnormal nails, dermatitis, peripheral neuropathy, nausea, diarrhea, fatigue, irritability, garlic odor of breath.

E.Surgical complications:

1.Short term:

a.Anastomotic leak—<1%–3% with Roux-en-Y gastric bypass (RYGB).

b.Gastrointestinal hemorrhage, bleeding—0.5% to 2%.

c.Wound infection—More common with open approach.

d.Thromboembolism—deep vein thrombosis (DVT), pulmonary embolism (PE), <1%.

e.Anastomotic strictures—Typically within first 3 months, nausea and/or vomiting.

f.Acute distention of the distal stomach.

g.Respiratory insufficiency, pneumonia.

2.Long term:

a.Band slippage—Abdominal pain, acid reflux, regurgitation, or dysphagia

b.Band erosion—May be asymptomatic, abdominal pain, gastrointestinal bleeding, weight loss, abdominal sepsis

c.Intestinal obstruction—Caused by internal hernias, adhesions, and anastomotic stenosis—colicky central abdominal pain, nausea, vomiting, abdominal distention, absolute constipation

d.Hepatobiliary complications—Rapid weight loss is associated with gallstone formation

e.Gastrointestinal bleeding—Rare and usually caused by ulceration

f.Marginal ulcers—Abdominal pain, vomiting, bleeding, or anemia

g.Micronutrient deficiencies

Other Signs and Symptoms

A.Expected weight loss:

1.LAGB—Initial loss of 40% to 50% of excess body weight in 3 to 5 years. Expected maintenance <50%.

2.GS—Initial loss of >50% of excess body weight in 3 to 5 years. Expected maintenance >50%.

3.RYGB—Initial loss of 60% to 80% of excess body weight in 1 year. Expected maintenance >50%.

4.Biliopancreatic diversion with duodenal switch (BPD/DS)—Initial loss of 60% to 70% of excess body weight in 1 year. Expected maintenance of 60% to 70%.

5.Intragastric balloons—Loss of about 10 to 15% of body weight is typical during the six months following intragastric balloon placement. Expected maintenance: The gastric balloon is only placed for 6 months then removed.

B.Weight regain of up to 20 lb. is common after 2 years.

C.Constipation and/or diarrhea may occur, depending on the procedure.

D.Weight loss of <25% of excess body weight is considered a surgical failure and may be revised.

E.Even if weight loss is adequate, patients may express disappointment and/or depression related to rate or amount of weight lost.

F.Nausea and vomiting after LAGB may indicate need for band adjustment.

Subjective Data

A.Review onset and duration of symptoms.

B.Elicit the date of surgery, type of surgery, and any reoperations or complications.

C.Review previous highest weight and amount of excess weight lost since surgery.

D.Evaluate the location and level of pain/discomfort.

E.Evaluate the overall psychosocial changes since surgery.

F.Review a 24-hour food recall, choices of healthy foods, skipping meals, food aversion (e.g., red meat), and intolerance.

G.Review medications and supplement use.

Physical Examination

A.Check height, weight, waist, and hip circumference. Calculate BMI, waist/hip ratio, pulse, respirations, and blood pressure. Check temperature if infection is suspected.

B.Inspect:

1.Examine the skin, evaluate surgical site(s), evaluate redness, and tenderness.

2.Oral/dental examination.

3.Evaluate for dehydration.

4.Eye examination: Evaluate eye movement (thiamine deficiency).

5.Evaluate gait.

6.General overview of personal presence and affect.

C.Auscultate:

1.Auscultate the heart and lungs.

2.Auscultate the abdomen for bowel sounds.

D.Palpate abdomen:

1.Evaluate for the presence of tenderness.

2.Evaluate for masses.

E.Neurologic examination:

1.Perform neurologic examination, including checking deep tendon reflexes (DTRs), sense of smell, and Babinski reflex (vitamin B12 deficiency).

Diagnostic Tests

A.Annual recommended laboratory testing for all procedures:

1.Complete blood count (CBC) with differential.

2.Liver function tests.

3.Glucose.

4.Creatinine.

5.Electrolytes.

B.Annual laboratory testing suggested for LAGB, recommended for all other procedures:

1.Iron/ferritin.

2.Vitamin B12.

3.Folate.

4.Calcium.

5.Intact parathyroid hormone (PTH).

6.25-hydroxy vitamin D.

7.Albumin/prealbumin.

C.Optional labs that may be required based on symptoms:

1.Zinc.

2.Copper.

3.Vitamin B1.

4.Vitamin B6.

5.Vitamin A every 24 months and beyond.

D.Other labs as appropriate for condition and prevention:

1.Monitor HgA1c and blood glucose closely in patients with diabetes. Diabetes has resolved after bariatric surgery in some patients.

2.Lipid profile.

E.Abdominal ultrasound.

F.CT scan abdomen.

G.Doppler ultrasound of limb for suspected DVT.

H.Pulmonary ventilation/perfusion scan for suspected pulmonary embolus.

I.Bone mineral density (DEXA) scan: Recommended annually until stable after malabsorptive procedures.

J.Endoscopy as needed for abdominal complaints.

Differential Diagnoses

A.Postoperative surgical complication(s):

1.Infection.

2.Abdominal pain.

3.Fascial dehiscence.

4.DVT.

5.Bowel obstruction.

6.Band slippage.

7.Anastomosis leakage.

8.Stomal stenosis/stricture.

B.Cholecystitis.

C.Dumping syndrome.

D.Food intolerance.

E.Gastric ulcer (GU).

F.Gastroenteritis.

G.Vitamin deficiency.

H.Malnutrition/protein deficiency.

I.Incisional hernia.

J.Osteoporosis.

Plan

A.General interventions:

1.Lifelong follow-up is required after bariatric surgery. Ideally, patients should follow up with their surgical group, but many do not. Primary care providers are well positioned to capture those lost to follow-up. Continuous reinforcement of good nutritional habits is important.

B.Patient teaching: Many complications can be prevented by adhering to diet and lifestyle recommendations:

1.Supplements are required lifelong; strict adherence will prevent deficiencies.

2.Dumping syndrome can be prevented by avoiding foods that trigger it such as high sugar and/or highfat foods. Patients can keep food diaries to identify triggers.

3.Hypoglycemia can usually be prevented by careful monitoring of carbohydrate intake.

4.Surgery does not replace the need for a balanced diet or exercise. Approximately 150 minutes of moderate activity each week is recommended, though safety and tolerance differs so exercise recommendations should be individualized. Any activity is better than none.

5.Food should be chewed thoroughly and consumed slowly. Liquids should be avoided 30 minutes before and after meals. Avoid eating and drinking liquids simultaneously.

6.Protein is important for maintaining muscle mass during rapid weight loss and avoiding hunger during maintenance. Between 60 and 100 g of protein daily is recommended. Limit carbohydrate intake to 50 gd or less. Limiting carbohydrate intake reduces risk of weight regain by preventing rebound hunger.

7.To prevent dehydration, as well as reduce the risk of kidney stones and constipation,

encourage 64 ounces of fluids daily.

8.Stress, boredom, and emotions often affect eating habits. Identifying problems and seeking help early are important.

9.Support groups can be a vital source of education and social support, both of which are key to weight loss and maintenance.

10.Weight plateaus are common and normal. This is the body’s way of trying to establish a new set point. Do not be discouraged by plateaus. Consistency is key to overcoming them.

11.Adequate sleep and successful stress management are also key to successful weight loss and maintenance.

C.Pharmaceutical therapy:

1.Medication absorption can be altered after bariatric surgery. Evaluate need for adjustments of medication dosing, especially diabetic, psychiatric, and antihypertensive medications as well as any medication with a narrow therapeutic window.

2.Patients may require alternate formulations of medications, including crushed, chewable, liquid, patches, intramuscular, or subcutaneous. Long-acting, extended-release, or enteric coated medications may not be absorbed as well and may need to be switched to immediate release.

Drugs with a small therapeutic window such as digoxin, carbamazepine, theophylline, and phenytoin should not be crushed due to the increase in toxicity.

3.Medications designed to release slowly should not be crushed or chewed because the full dose will be released faster than expected. A resource guide for crushing medications is available at www.ismp.org/recommendations/do-not-crush.

4.Universal postoperative supplementation (see Table 14.26):

a.Multivitamin and mineral supplementation:

i.LAGB: One daily.

ii.All other procedures: Two daily (take each dose at a separate time).

iii.Tablets, cChewable, or Lliquid.

b.Calcium:

i.LAGB, GS, RYGB1, 200 to 1,500 mg daily from food and supplements.

ii.BPD/DS—-1,800 to -2,400 mg daily from food and supplements.

iii.Calcium citrate should be taken in divided doses (23 doses of 500 mg).

iv.Chewable or liquid.

c.Vitamin D3: (all procedures):

i.3,000 international unit (IU) daily, titrate to therapeutic level.

ii.Vitamin D should be taken with the calcium supplement.

d.Iron

i.18 mg/d elemental iron.

ii.RYGB, SG, BPD/DS 45 to 60 mg daily from multivitamin plus additional supplementation.

iii.Menstruating women: 45 to 60 mg/d.

iv.Iron should be taking separately at least 2 hours apart from calcium supplements.

v.Iron should not be taken with milk products.

e.Vitamin B12 (cobalamin):

i.Oral or sublingual: 350 to 500 mcg/d.

ii.Intranasal: 1,000 mcg/wk.

iii.Intramuscular 1,000 mcg/month.

f.Folate (folic acid)

i.400 to-800 mcg/d.

ii.Women of childbearing age: 800 to 1,000 mcg/d.

g.Vitamin A

i.LAGB: 5000 IU/d.

ii.RYGB or SG: 5,000 to 10,000 IU/d.

iii.BPD/DS: 10,000 IU/d.

h.Vitamin E: (all procedures) 15 mg/d.

i.Vitamin K:

i.LAGB, SG or RYGB: 90 to 120 mcg/d.

ii.BPD/DS: 300 mcg/day.

j.Zinc:

i.SG or LAGB: 8 to 11 mg/d.

ii.RYGB: 8 to 22 mg/d.

iii.BPD/DS: 16 to 22 mg/d.

k.Copper:

i.SG or LAGB: 1 mg/d.

ii.RYGB or BPD/DS: 2 mg/d.

l.Long-term anticoagulation may be needed for DVT/PE prophylaxis.

m.Nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids should be avoided to reduce the risk of marginal ulcers.

D.Psychosocial changes: Bariatric surgery often results in dramatic lifestyle and body changes and may require significant psychosocial adjustments for the patient as well as his or her friends and family:

1.Monitor for depression/anxiety, body image concerns, and social support.

2.Alcoholism can be a concern after bariatric surgery. Less alcohol is needed to elevate blood alcohol levels and blood alcohol levels are sustained longer after bariatric surgery.

Follow-Up

A.Bariatric surgery requires lifelong follow-up, ideally by a multidisciplinary team of healthcare providers. Initial followup schedules are set by the surgeon. Long-term follow-up (after the first 2 years) is usually provided for by the bariatric surgery program.

B.Medications with narrow therapeutic windows and medication are dosed based on weight should be evaluated frequently.

C.Annual laboratory and diagnostic testing is required (refer to Diagnostic Tests). Early recognition of nutritional deficiencies can prevent permanent damage and even death.

D.Chronic disease management (particularly diabetes, lipids, and bone disease) can be simpler or more complex after bariatric surgery, depending on the patient’s adherence to lifestyle and nutritional recommendations.

Consultation/Referral

A.Bariatric surgeon for surgical complications, revisions.

B.Surgeon for cholecystectomy (preferably bariatric surgeon or general/gastrointestinal (GI) surgeon experienced in the care of bariatric patients).

C.Gastroenterology consult.

D.Nutrition consultation and/or counseling.

E.Psychologist consultation.

F.Physical therapy/exercise specialist.

G.Support group.

Individual Considerations

A.Women:

1.All women of childbearing age should receive adequate folate supplementation and be given contraception and preconception counseling.

2.oral contraceptives (OCPs) may not be as effective after bariatric surgery because of changes in absorption.

B.Pregnancy:

1.Pregnancy should be delayed for 12 to 18 months after bariatric surgery or however long it takes for weight loss to stabilize.

2.Bariatric surgeon consult may be required.

3.Increased folic acid may be needed preconception to reduce risk of neural tube defects.

4.Increased vitamin supplementation may be necessary during pregnancy. Vitamin A should be limited to 5,000 IU daily.

5.Gastric band may need to be adjusted during pregnancy.

6.Serial ultrasounds may need to be done to follow fetal growth.

C.Geriatrics:

1.Discussion of bariatric surgery in the elderly (over 60 years of age) is controversial. However, the patient should not be denied bariatric surgery because of age. Mortality rate was 0.01%, complication rate ranged from 9.7%- to14.7%. At 1-year follow-up, excess weight loss was approximately 53.77% with improvement of diabetes by 54.5%, hypertension improvement was 42.5% and cholesterol improvement was 41.2%.

Definition

Incidence

Pathogenesis

Predisposing Factors

Common Complaints

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