Issue: 2015, Vol 1, No 2, Pages 41–79

Ten Top Tips for the management of patients post-bariatric surgery in primary care

Helen Mary Parretti, Carly Anna Hughes, Mary O’Kane, Sean Woodcock, Rachel Gillian Pryke

Helen Mary Parretti, Carly Anna Hughes, Mary O’Kane, Sean Woodcock, Rachel Gillian Pryke
Helen Parretti is NIHR Clinical Lecturer, University of Birmingham; Carly Hughes is Clinical Lead, Fakenham Weight Management Service, and GP Research Fellow and Honorary Lecturer, University of East Anglia, Norwich; Mary O’Kane is Consultant Dietitian (Adult Obesity), Leeds Teaching Hospitals NHS Trust; Sean Woodcock is Consultant Upper GI and Bariatric Surgeon, North Tyneside Hospital; Rachel Pryke is GP, Winyates Health Centre, Redditch, and Chair of the RCGP Nutrition Group.

In the UK, NICE recognises that bariatric surgery may be an appropriate and costeffective treatment for obesity. Following changes to the eligibility criteria to undergo bariatric surgery in the CG189 clinical guidelines (NICE, 2014), the number of procedures being performed per year is likely to increase. People who undergo such surgery require lifelong followup of their comorbidities and nutritional status. Guidance has been developed by the Royal College of GPs (RCGP) Nutrition Group in conjunction with the British Obesity and Metabolic Surgery Society (BOMSS) to aid GPs in providing high-quality shared care of these patients with Tier 3 or 4 teams.

Ten Top Tips for the management of patients post-bariatric surgery in primary care

Currently, according to the National Bariatric Surgery Registry (Welbourn et al, 2014), around 8500 procedures are performed in the UK each year. This is a complex cohort of patients, with an average of 3.4 comorbidities pre-surgery in women and 3.7 in men. This includes four or more comorbidities in 53.9% of men and 41.4% of women. While bariatric surgery has been reported to have significant benefits with regard to the improvement and remission of these comorbidities (Puzziferri et al, 2014; Sjöström et al, 2014; Welbourn et al, 2014), it also puts patients at risk of nutritional deficiencies (Aarts et al, 2011; Mechanick et al, 2013).

People who undergo bariatric surgery require lifelong follow up of their comorbidities and monitoring of their nutritional status. CG189 suggests that after the first 2 years post-procedure, care should be carried out by primary care in a shared-care model with a named Tier 3 service or equivalent (NICE, 2014). This should include an annual review which, for many patients, will coincide with their annual comorbidity monitoring. In 2013, the American Association of Clinical Endocrinologists, The Obesity Society and the American Society for Metabolic and Bariatric Surgery published joint guidelines for the perioperative care of people undergoing bariatric surgery (Mechanick et al, 2013).

However, currently, there are no comprehensive guidelines that focus on the long-term care of post-bariatric surgery patients within primary care. Therefore, the RCGP Nutrition Group has developed these guidelines in conjunction with BOMSS through review of the current literature and expert opinion. The guidance is specifically aimed at all non-specialist clinicians, dietitians and nurses to aid management of these people once they are discharged back to primary care, and also to aid management of any patients for whom follow-up guidance from the surgical team is not available.

It is important to note that people who have moved to a different area or who undergo a private procedure are likely to have had less specialist follow-up and may need to be managed in primary care earlier post-procedure. In addition, any new concerns should always trigger referral to a Tier 3 weight management service (if available) or the local bariatric surgery team for further advice.

Top Tip One

Keep a register of bariatric surgery patients

It is important to record the type of procedure in the register, as the different procedures have different risks of nutritional deficiencies. This is also essential information to include when liaising with specialist services.

Top Tip Two

Encourage patients to check their own weight regularly and to attend an annual BMI and diet review with a healthcare professional

Do not assume that all patients are eating a well-balanced diet. Some may have maladaptive eating patterns and poor nutritional intake. If BMI is increasing, consider referral to local weight management services to support and encourage lifelong weight maintenance.

Top Tip Three

Symptoms of continuous vomiting, dysphagia, intestinal obstruction (gastric bypass) or severe abdominal pain require emergency admission under the local surgical team

Further details of both urgent and routine indications for referral back to specialist services are summarised in a printable “at a glance” poster that can be found on the RCGP nutrition web pages (available at: http://bit.ly/1Ddt6yT).

Top Tip Four

Continue to review comorbidities postsurgery, including diabetes, hypertension, hypercholesterolaemia and obstructive sleep apnoea, as well as mental health

Medication doses will need to be titrated in the postoperative period as weight loss occurs, but they may increase later if weight loss is not maintained. Studies have shown very positive results with regard to remission of diabetes post-surgery (Brethauer et al, 2013; Puzziferri et al, 2014; Sjöström et al, 2014), and people with diabetes need regular medication reviews, with treatment adjustments as required. However, longer-term studies have shown that some patients have a recurrence of diabetes (Brethauer et al, 2013; Sjöström et al, 2014). Therefore, people with diabetes should also continue to have routine diabetes follow-up (i.e. they should be kept on the Quality and Outcomes Framework diabetes register and receive annual retinopathy screening) even if their diabetes goes into remission. Whether or not weight loss occurs, cardiovascular and metabolic risk factors, such as blood pressure and cholesterol levels, must continue to be monitored, and treatments will need to be adjusted as required. Patients receiving continuous positive airway pressure should continue to use their machines until they have had a repeat sleep study performed post-surgery (Duke and Finer, 2012).

It is worth noting that there is a higher rate of mental health problems in people with severe and complex obesity compared with the general population (Vaidya, 2006; Gundersen et al, 2011), and these problems may persist even after successful bariatric surgery. Therefore, mental health should be reviewed regularly following surgery. The psychological management of these people can be complex and, therefore, there should be a low threshold for referral to specialist mental health services.

Top Tip Five

Review the patient’s regular medications

The formulations may need adjusting post-surgery to allow for changes in bioavailability. This is - particularly relevant in people who undergo gastric bypass or duodenal switch. It is crucial that medications for comorbidities are closely monitored and adjusted as discussed in Top Tip Four. Other medication considerations are shown in Box 1 (Thomas and Taub, 2011).

Box 1. Medication considerations post-bariatric surgery.
  • Review comorbidity medications, such as antihypertensives, diabetes medications, etc., post-surgery. Requirements are likely to fall with postoperative weight loss, but may increase later if weight loss is not maintained.
  • Consider pill size – patients may need liquid formulations or syrups in the immediate postoperative period. However, usual medication formulations should be tolerated by around 6 weeks postoperatively.
  • Replace extended-release formulations with immediate-release formulations.
  • Psychiatric medications may need increased or divided doses.
  • Use diuretics with caution due to the increased risk of hypokalaemia.
  • Monitor anticoagulants carefully.
  • Avoid non-steroidal anti-inflammatory drugs; if no alternative, use only with a proton pump inhibitor.
  • Avoid bisphosphonates.
  • Patients with gastric bands should avoid effervescent medications.

Top Tip Six

Bariatric surgery patients require lifelong annual blood tests, including micronutrient monitoring

Encourage patients to attend their annual blood tests. Use patient record reminders, where available, to prompt that annual blood testing is required, depending on practice computer systems. An annual audit of patient monitoring is recommended to ensure that correct follow-up is being performed. The recommended tests are shown in Table 1 (Heber et al, 2010; Mechanick et al, 2013; O’Kane et al, 2014a; 2014b). Note that people who undergo gastric banding require annual full blood counts, urea and electrolyte tests, and liver function tests, but these should be carried out earlier if there are any concerns regarding the band.

Figure 1

Top Tip Seven

Be aware of potential nutritional deficiencies that may occur and their signs and symptoms

Liaise with the local Tier 3 or 4 specialist unit regarding any deficiencies and their treatment. In particular, patients are at risk of anaemia and vitamin D deficiency, as well as protein malnutrition and other vitamin and micronutrient deficiencies. If a patient is deficient in one nutrient they are likely to be deficient in others as well, so it is advised to screen for these. Clinicians should be aware of the potential nutritional deficiencies listed in Table 2 (Heber et al, 2010; Mechanick et al, 2013; O’Kane et al, 2014a; 2014b).

Figure 1

Top Tip Eight

Ensure the patient is taking the appropriate lifelong nutritional supplements as recommended by the bariatric centre

Patients will need lifelong supplements, and guidance should have been given by the bariatric unit on discharge, as the supplementation required depends on both the procedure and the patient’s individual requirements. Examples of the usual minimal supplements are listed in Table 3 for each type of procedure; however, see O’Kane (2014b) for full guidance. If guidance on supplements has not been given on discharge, we would advise clinicians to always liaise with the Tier 4 bariatric unit in the first instance.

Figure 1

Top Tip Nine

Discuss contraception – ideally pregnancy should be avoided for at least 12–18 months post-surgery

A long-acting, reversible contraceptive of the patient’s choice would be appropriate. Oral contraception and Depo-Provera are not recommended because of issues with absorption and weight gain, respectively.

Top Tip Ten

If a patient should plan or wish to become pregnant after bariatric surgery, alter their nutritional supplements to one suitable during pregnancy

Additional monitoring and supplementation may be required. Inform the local bariatric unit (ideally prior to conception) so that the patient can be reviewed by a bariatric dietitian. In addition, people who undergo gastric band surgery may need their band adjusting on becoming pregnant to allow good nutritional intake and fetal growth. The obstetric team should also be informed of the patient’s history of bariatric surgery as soon as possible, as there may be a higher rate of firsttrimester miscarriages in this cohort of patients (Guelinckx et al, 2009). Recommended changes to treatment before and during pregnancy are as follows (Duke and Finer, 2012; O’Kane et al, 2014a; 2014b):
- Change nutritional supplement to one that is appropriate in pregnancy, such as Pregnacare or Boots Pregnancy Support.
- If a proton pump inhibitor is needed, omeprazole is recommended.
- Continue vitamin D supplementation as indicated by vitamin D levels and as per National Osteoporosis Society guidance (Francis et al, 2013).
- Continue vitamin B12 injections in those currently receiving them, or monitor levels in those not receiving them (for sleeve gastrectomy patients).
- Once-daily iron 200 mg is recommended.
- Once-daily folic acid 5 mg is recommended.

Conclusions

The long-term management of an increasing number of people who undergo bariatric surgery is likely to involve primary care clinicians, and guidance on how to manage these patients safely and appropriately within primary care is essential. Here, we have presented guidance for the followup of these people by non-specialist healthcare professionals working in primary care, and it is hoped that this guidance from the RCGP Nutrition Group will aid the shared care of these patients.

Acknowledgements

The authors would like to thank Dr Rachel Batterham for her comments and advice during the development of this guidance.

Further information

The printable short leaflet and extended versions of the Ten Top Tips guidance are available on the RCGP nutrition web pages, together with the poster outlining referral criteria for post-surgery complications.

The short leaflet is available at: http://bit.ly/1zzyfxp The extended version is available at: http://bit.ly/1wVfNl3

The poster outlining both urgent and routine indications for referral back to specialist services is available at: http://bit.ly/1Ddt6yT

Aarts EO, Janssen IM, Berends FJ (2011) The gastric sleeve: losing weight as fast as micronutrients? Obes Surg 21: 207–11

Brethauer SA, Aminian A, Romero-Talamás H et al (2013) Can diabetes be surgically cured? Long-term metabolic effects of bariatric surgery in obese patients with type 2 diabetes mellitus. Ann Surg 258: 628–36

Duke E, Finer N (2012) Bariatric Surgery: Pre-Operative and Post-Operative Care. Information for General Practitioners. UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, London.

Francis R, Aspray T, Fraser W et al (2013) Vitamin D and Bone Health: A Practical Clinical Guideline for Patient Management. National Osteoporosis Society, Bath. Available at: http://bit.ly/1zCzrR2 (accessed 20.04.15)

Guelinckx I, Devlieger R, Vansant G (2009) Reproductive outcome after bariatric surgery: a critical review. Hum Reprod Update 15: 189–201 Gundersen C, Mahatmya D, Garasky S, Lohman B (2011) Linking psychosocial stressors and childhood obesity. Obes Rev 12: e54–63

Heber D, Greenway FL, Kaplan LM et al (2010) Endocrine and nutritional management of the post-bariatric surgery patient: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 95: 4823–43

Mechanick JI, Youdim A, Jones DB (2013) 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. Obesity (Silver Spring) 21(Suppl 1):1–27

NICE (2014) Obesity: Identification, Assessment and Management of Overweight and Obesity in Children, Young People and Adults (CG189). NICE, London. Available at: www.nice.org.uk/guidance/cg189 (accessed 20.04.15)

O’Kane M, Pinkney J, Aasheim ET et al (2014a) GP Guidance: Management of Nutrition Following Bariatric Surgery. BOMSS, London. Available at: http://bit.ly/1EkdzBr (accessed 20.04.15)

O’Kane M, Pinkney J, Aasheim ET et al (2014b) BOMSS Guidelines on Peri-Operative and Postoperative Biochemical Monitoring and Micronutrient Replacement for Patients Undergoing Bariatric Surgery. BOMSS, London. Available at: http://bit.ly/1HnZTV0 (accessed 20.04.15)

Puzziferri N, Roshek TB, Mayo HG et al (2014) Long-term follow-up after bariatric surgery: a systematic review. JAMA 312: 934–42 Sjöström L, Peltonen M, Jacobson P et al (2014) Association of bariatric surgery with long-term remission of type 2 diabetes and with microvascular and macrovascular complications. JAMA 311: 2297–304

Thomas CM, Taub LF (2011) Monitoring for and preventing the longterm sequelae of bariatric surgery. J Am Acad Nurse Pract 23: 449–58

Vaidya V (2006) Psychosocial aspects of obesity. Adv Psychosom Med 27: 73–85

Welbourn R, Small P, Finlay I et al (2014) The United Kingdom National Bariatric Surgery Registry. NBSR, London. Available at: http://bit.ly/1dG01nF (accessed 20.04.15)