Long-Term Care of the Bariatric Patient

Educational Objectives

The goal of this program is to improve long-term management following bariatric surgery. After hearing and assimilating this program, the clinician will be better able to:

1. Perform appropriate postoperative evaluation of patients who have undergone bariatric surgery.
2. Manage complications of bariatric surgery.

Summary

Bariatric surgery: although eligibility for and utilization of bariatric surgery have increased, a treatment gap remains; barriers include fears about or bias against surgery and use of endoscopic procedures and medication; surgery is the most durable treatment for long-term weight loss and resolution of comorbidities; the morbidity and mortality associated with bariatric surgery decreased with the advent of minimally invasive (ie, laparoscopic, robotic) procedures; sleeve gastrectomy is the most common procedure, followed by gastric bypass; revision procedures (eg, conversion to a different procedure, correction of the original procedure) are increasingly performed for patients who have complications or desire additional weight loss

Evaluation: bariatric surgery is recommended for individuals with a body mass index (BMI) >40, or >35 with comorbidities; updated guidelines from the American Society for Metabolic and Bariatric Surgery suggest evaluation of individuals with a BMI >35 without comorbidities, BMI of 30 to 35 with underlying metabolic disease, and BMI ≥25 in Asians; insurance companies do not currently follow these guidelines

Surgical options: restrictive procedures include adjustable gastric bands and sleeve gastrectomy; procedures causing malabsorption include gastric bypass and duodenal switch (eg, single anastomosis duodenal switch)

Routine postoperative care: vitamin and mineral supplementation — required to compensate for decreased food intake and changes in nutrient absorption; after sleeve gastrectomy and Roux-en-Y gastric bypass, patients need a complete multivitamin supplemented with thiamine, vitamin B₁₂, iron, and biotin; calcium should be given at 1200 to 1500 mg/day (in split doses), with vitamin D and magnesium to improve absorption; patients who have undergone duodenal switch have malabsorption of fat-soluble vitamins (A, D, E, and K); use a complete multivitamin with higher levels of fat-soluble vitamins or use individual supplements; patients also need increased calcium and iron; iron should be taken with vitamin C; annual laboratory tests — iron-deficiency anemias are common; order a complete blood count, ferritin and iron levels, iron-binding capacity, and levels of D, A, and B vitamins; check glycosylated hemoglobin, lipids, and thyrotropin on a case-by-case basis; follow-up — at 1 wk, 1 mo, 3 mo, 6 mo, and 1 yr, and annually thereafter; patients often follow up with primary care or gastroenterologists after ≈2 yr; lifestyle — patients should avoid pregnancy for the first 1 to 2 yr after surgery because of potential vitamin and protein deficiencies; patients should avoid alcohol for ≥1 yr (after 1 yr, assess for signs of excessive use or maladaptive behaviors; nonsteroidal anti-inflammatory drugs (NSAIDs) are discouraged in the immediate postoperative period (contraindicated lifelong in individuals who have undergone gastric bypass or duodenal switch); nicotine use is contraindicated for all patients

Long-term complications: deficiencies of calcium and vitamin D — may lead to osteoporosis or osteopenia; if baseline laboratory tests indicate risk for deficiency, perform a baseline bone density scan; check bone density in all patients 2 yr after surgery; bone loss is most common in the hip or spine; if present, check calcium, phosphorous, parathyroid hormone, and 24-hr urinary calcium; iron deficiency anemia — less common with sleeve gastrectomy but may occur in ≤62% of individuals who have undergone duodenal switch; obtain screening tests and treat with 150 to 200 mg iron daily in split doses; iron must be consumed separately from calcium, proton pump inhibitors, and H2 blockers (which interfere with iron absorption); protein malnutrition — an early sign is hair loss that persists >6 mo after surgery; daily protein intake should be ≥1g/kg/day; late signs of severe secondary kwashiorkor include edema, dermatosis, pancreatic insufficiency, and steatohepatitis; if present, additional enteral support or parenteral feeding may be required; surgical revision or reversal is indicated for refractory deficiency (occurs in <5%)

Weight regain: some degree is expected in the postoperative period; weight loss occurs in the first 1 to 2 yr; patients typically gain ≈10 lb at ≈2 yr, then stabilize; ≈15% of patients gain more weight or even return to their preoperative weight (more common after adjustable gastric banding; more common with sleeve gastrectomy than gastric bypass); persistent weight gain requires evaluation by the bariatric surgeon; the issue is usually multifactorial; upper gastrointestinal radiographs evaluate anatomic issues (eg, gastrogastric fistula, ie, communication between the remnant stomach and surgical pouch); weight regain in patients with hiatal hernia occurs when diet is changed to offset symptoms; consider behavioral, environmental, and psychosocial factors; some patients have a genetic or biologic predisposition for regain

Obesity treatment pyramid: the foundation of obesity management is dietary and behavioral modification; medications for additional weight loss after bariatric surgery are now available; selected individuals may undergo endoscopic or surgical revision (eg, conversion of sleeve gastrectomy to gastric bypass, limb distalization for gastric bypass, stoma revision after gastric bypass)

Abdominal pain: appendicitis, diverticulitis, and gallbladder disease are common after bariatric surgery; internal hernias are specific to patients who have had gastric bypass or duodenal switch; gallbladder disease — obtain a history, perform a physical examination, and obtain right upper quadrant ultrasonography; typically develops ≤1 yr of surgery, when weight loss is rapid; because cholecystectomy combined with bariatric surgery has higher morbidity, routine cholecystectomy is not recommended if patients are asymptomatic and do not have gallstones; 3% to 13% of patients who undergo gastric bypass and 2% to 20% of individuals who undergo sleeve gastrectomy require cholecystectomy at some point

Marginal ulcers: as a source of abdominal pain, unique to patients who have had a gastric bypass; ulceration occurs at the gastrojejunostomy or on the jejunum; the gastric pouch secretes some acid but is not coated by protective bile and digestive secretions; incidence is 5% to 8% in individuals with gastric bypass and ≤12% in individuals who had sleeve gastrectomy converted to bypass; patients experience epigastric pain with eating that may mimic gallbladder symptoms; traditional diagnostic workup is required; risk factors — smoking, NSAIDs, and steroids (modifiable), pouch ischemia, pouch dilatation, and gastrogastric fistula; endoscopy is the preferred diagnostic procedure; treatment — open-capsule proton pump inhibitors decrease time to resolution from 1 yr to 3 mo; supplement with carafate and misoprostol; anatomic causes or refractory ulceration indicate surgery

Internal hernia: the lifetime risk for bowel obstruction related to internal hernia is 1% to 5%; patients typically present with abdominal pain and symptoms of obstruction; potential spaces created during gastrojejunostomy are closed during surgery, but weight loss may open up these spaces, leading to internal hernia; as internal hernia may be missed on imaging, a high index of suspicion is required; ask for surgical evaluation

Gastroesophageal reflux disease (GERD): de novo GERD develops at a high rate (15%-40%) following sleeve gastrectomy; patients with a history of severe GERD should undergo gastric bypass; studies reveal ≤11% incidence of Barrett esophagus after sleeve gastrectomy, compared with 1.6% in the general population; patients who have had sleeve gastrectomy should undergo screening endoscopy 3 to 5 yr after surgery, even in the absence of GERD symptoms; refer patients with reflux symptoms for evaluation for revision

Adjustable banding: a prosthetic band is placed distal to the gastroesophageal junction and inflated to provide restriction; complications include slippage, erosion, mechanical problems, and esophageal dysmotility; no longer performed; on abdominal radiography, the normal φ angle between the spine and band is ≈45 degrees; an angle >60 degrees indicates slippage and potential for obstruction (refer for surgical evaluation); band erosion — symptoms are subtle and include loss of restriction, new-onset reflux, and cellulitis at the port site; assessed endoscopically; treatment is surgical or endoscopic removal of the band

Readings

Eisenberg D, Shikora SA, Aarts E, et al. 2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) Indications for Metabolic and Bariatric Surgery [published correction appears in Obes Surg. 2022 Nov 29;:]. Obes Surg. 2023;33(1):3-14. doi:10.1007/s11695-022-06332-1; Goel R, Nasta AM, Goel M, et al. Complications after bariatric surgery: A multicentric study of 11,568 patients from Indian bariatric surgery outcomes reporting group. J Minim Access Surg. 2021;17(2):213-220. doi:10.4103/jmas.JMAS_12_20; Gowanlock Z, Lezhanska A, Conroy M, et al. Iron deficiency following bariatric surgery: a retrospective cohort study. Blood Adv. 2020;4(15):3639-3647. doi:10.1182/bloodadvances.2020001880; Lim R, Beekley A, Johnson DC, et al. Early and late complications of bariatric operation. Trauma Surg Acute Care Open. 2018;3(1):e000219. Published 2018 Oct 9. doi:10.1136/tsaco-2018-000219; Noria SF, Shelby RD, Atkins KD, et al. Weight regain after bariatric surgery: scope of the problem, causes, prevention, and treatment. Curr Diab Rep. 2023;23(3):31-42. doi:10.1007/s11892-023-01498-z; Sherf Dagan S, Goldenshluger A, Globus I, et al. Nutritional recommendations for adult bariatric surgery patients: Clinical practice. Adv Nutr. 2017;8(2):382-394. Published 2017 Mar 15. doi:10.3945/an.116.014258; Stenberg E, Dos Reis Falcão LF, O'Kane M, et al. Guidelines for perioperative care in bariatric surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations: A 2021 Update [published correction appears in World J Surg. 2022 Jan 29;:]. World J Surg. 2022;46(4):729-751. doi:10.1007/s00268-021-06394-9.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Tatarian was recorded at the 5th Annual Jefferson Women and Gastroenterology Health Symposium, held in Philadelphia, PA, on February 24, 2023, and presented by Sidney Kimmel Medical College at Thomas Jefferson University. For information about upcoming CME activities from this presenter, please visit jefferson.cloud-cme.com. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

GE371402

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.