Tuesday, June 28, 2016
After Bariatric Surgery
Primary care providers must consider unique issues in this patient population
A nurse practitioner completes the examination of a longtime patient who presents to the clinic for a sinus infection that requires antibiotic treatment. When the NP offers the prescription, the patient says, "I need a liquid antibiotic." Further questioning reveals that the patient underwent laparoscopic adjustable gastric band (LAGB) surgery 2 years earlier; it had not been included on the recently updated health history.
The options available to treat obesity are combinations of diet, exercise, support, and pharmacologic and surgical interventions. Bariatric surgery is a popular choice, as evidenced by the number of such surgeries performed in the United States: around 113,000 per year. An additional 350,000 to 750, 000 patients undergo bariatric procedures in other countries.1-3 This means that many primary care providers will treat a patient who has undergone a weight loss surgery.
The patient who chooses bariatric surgery for weight loss requires lifelong follow-up, monitoring and care. Patients who have consistent follow-up achieve greater weight loss.2 However, systematic review of bariatric surgery cases indicates that long-term follow-up may be insufficient; no research has followed patients beyond 5 years.4 Most research has focused on the initial follow-up period. A gap in care occurs when bariatric surgery patients stop follow-up with their surgeon and transition to the primary care setting.
Types of Bariatric Surgery
Historically, bariatric options have been classified as restrictive or malabsorptive.5 These classifications are no longer relevant because the focus of bariatric surgery has moved from weight loss to improving the metabolic effects of obesity.2 Most bariatric procedures are now performed laparoscopically, but earlier in the history of bariatric surgery, open surgery was common. Prior abdominal surgery may necessitate an open procedure today.
The Rou-en-Y gastric bypass (RYGB) was first performed in the 1960s and is one of the most common weight loss procedures in the United States.6 It has been performed laparoscopically since the 1990s.5 In this surgery, the surgeon creates a small gastric pouch with a 10- to 20-mL capacity. It is completed with a Roux-en-Y gastrojejunostomy that allows food to bypass a portion of the stomach, duodenum and proximal jejunum.5,6 The RYGB is associated with excellent weight loss results, and it requires no adjustments or implants. The disadvantages are dumping syndrome, the potential for staple line leak, ulcers, and the lifelong need for nutritional supplements.7
Dumping syndrome can occur early or late, based on when the symptoms of diaphoresis, flushing, palpitations, abdominal pain and diarrhea occur after eating.7,8 Educating the patient to avoid simple sugars, simple carbohydrates and greasy foods, to eat six small meals a day, to avoid drinking liquids for at least 30 minutes after eating, and increasing fiber intake are strategies that may help the patient deal with this problem.8 Staple line leaks generally present during the immediate postoperative period and are usually associated with tachycardia, abdominal pain and nausea and vomiting.7 Patients presenting with these symptoms should be referred to their bariatric surgeon or emergency department for further evaluation.
Regarding the need for nutritional supplements, the patient should continue to take multivitamins and undergo monitoring of lab values for micronutrients. Patients presenting with neurologic symptoms should be evaluated for thiamine deficiency and require further evaluation and treatment.8 Patients should also be encouraged to maintain hydration by drinking at least 1.5 liters of water daily.8
The sleeve gastrectomy (SG), also called a vertical sleeve gastrectomy or gastric sleeve,5 is now a popular bariatric surgery option.2 In this procedure, a large portion of the stomach is removed to create a sleeve-shaped stomach.7 It produces good weight loss results with fewer complications than RYGB. The disadvantages are potential for blockages or stricture, potential for staple line leak or ulceration, and permanence.7 Long-term consequences (and their associated needs) have not been fully studied. Signs and symptoms of staple line leak are the same as with the RNYGB, as previously discussed. The patient with a SG should also be monitored for vitamin deficiencies.
The laparoscopic adjustable gastric band (LAGB) procedure is another popular option. This procedure involves the placement of a band around the stomach, which creates a small stomach pouch. The band can be adjusted with the insertion of saline to create more restriction.6,7 LAGB surgery requires more frequent, specific follow-up and monitoring for adjusting the amount of restriction the patient experiences, as well as monitoring for the disadvantages associated with LAGB. The disadvantages of the LAGB are slower weight loss compared to other procedures, the risk of band slippage, and band erosion.7 7 Signs of these complications are nausea, solid food intolerance, ulcer and epigastric pain.9
The biliopancreatic diversion (BPD) with duodenal switch or the duodenal switch (DS) is an option for severe obesity and is associated with greater risk than LAGB.5 This procedure involves a sleeve gastrectomy procedure with a long intestine bypass.7 While this procedure provides the patient with excellent maintainable weight loss, it is associated with malabsorption and increased stool frequency.2,7 Care is supportive for these problems. Ensure the patient is taking multivitamins to help prevent vitamin deficiencies. Increased fiber may help reduce the diarrhea.
Older, less prevalent bariatric procedures include vertical banded gastroplasty (VBG) or "stomach stapling,"5 which was developed in the 1980s. In VBG, the surgeon creates a hole in the stomach and makes a line of staples from the hole to the esophagus, creating a small pouch. The surgeon then anchors the pouch with a band.5 Bariatric surgeries performed in the 1980s and 1990s incorporated a variety of nonadjustable bands, one of which is the Molina band.9 These bands may still be present in patients seen today. They should be monitored for band slippage and erosion as with the LAGB
The primary care presentation of a patient who has undergone bariatric surgery raises particular issues. First, the primary care provider should determine if the patient has been following up with his or her surgeon and the length of time since surgery. Laboratory testing of bariatric patients is typically performed every 3 months the first year and annually thereafter.7,10 Most sources recommend performing the following lab studies yearly after bariatric surgery: complete blood count (CBC), chemistry panel, iron, ferritin, vitamin B12, parathyroid hormone (PTH) and fat-soluble vitamins.7,10 Due to potential bone loss associated with significant weight loss, bone density studies are recommended 1 to 5 years after surgery.7,10
Certain considerations are important when prescribing medications to this patient population. Bariatric patients should take a daily multivitamin at bedtime. This dosing increases absorption of the vitamins due to slowed peristalsis while sleeping. Depending on which surgery was performed, medication characteristics should be considered. In the case described at the start of this article, the LAGB patient requested a liquid antibiotic to reduce the risk of the pill becoming obstructed by the band. Nonsteroidal anti-inflammatory (NSAID) medications can increase the risk of anastomotic ulcers and should be used cautiously in bariatric patents with an anastomosis.7 If an NSAID is necessary, the provider should prescribe a proton pump inhibitor (PPI) too. Diuretics can increase the risk of dehydration and renal impairment in bariatric patients.7
Comorbid conditions such as diabetes, hypertension, sleep apnea, gastroesophageal reflux disease (GERD) and hyperlipidemia should be monitored. Improvement or remission has occurred in patients with diabetes, hypertension or hyperlipidemia.4 Patients with sleep apnea should be reevaluated before they stop using continuous or bilevel positive airway pressure (CPAP or BIPAP). The patient may require treatment of their GERD with a PPI. While bariatric surgery may improve these comorbid conditions for patients who have undergone surgery, monitoring for these common health problems is still necessary.
Continued support of the bariatric patient is important for long-term success. Studies show that patients who have consistent follow-up have improved weight loss compared to patients whose follow-up is poor.2 Continue to reinforce diet and exercise as tools to help the patient with continued weight loss or weight maintenance. These patients need to be encouraged to participate in support groups.
The bariatric patient should be monitored for long-term complications of the surgery. Since each bariatric procedure has its own benefits and disadvantages, it is important to identify which bariatric procedure was performed. Referral or communication with a bariatric surgeon should occur when any bariatric patient presents with abdominal pain. This can indicate a serious problem. Patients with a history of RYGB may be at risk for an internal hernia, intestinal obstruction, or a staple line leak.7 Patients who underwent LAGB are at risk of band slipping or erosion.7 These patients may present with nausea, vomiting or abdominal pain. Other symptoms that may indicate a need for referral are fever, tachycardia, shoulder pain, and liquid intolerance lasting more than 24 hours.7
Patients who choose a surgical option for weight loss require lifelong considerations and monitoring. Primary care providers must be aware of the specific needs of bariatric surgery patients. The key is to identify the type of bariatric surgery that was performed and to learn about its postsurgical issues. Then, partner with them to ensure their continued health.
1. Birch DW, et al. Medical tourism in bariatric surgery. Am J Surg. 2010;199(5):604-608.
2. Mechanick J, et al. 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 the American Society for Metabolic & Bariatric Surgery. Obesity. 2013;21(Suppl 1):S1-s27.
3. Livingston EH. The incidence of bariatric surgery has plateaued in the U.S. Am J Surg. 2010;200(3):378-385.
4. Puzziferri N, et al. Long-term follow-up after bariatric surgery: A systematic review. JAMA. 2014;312(9):934-942.
5. Gagnon L, et al. Outcomes and complications after bariatric surgery. Am J Nurs. 2012;112(9):26-36.
6. Presutti RJ, et al. Primary care perspective on bariatric surgery. Mayo Clin Proc. 2004;79(9):1158-1166.
7. Thomas C, et al. Monitoring for and preventing the long-term sequelae of bariatric surgery. Am Acad Nurse Pract. 2011;23(9):449-458.
8. Bosnic G. Nutritional requirements after bariatric surgery. Crit Care Nurs Clin N Am. 2014;26(2):255-262.
9. Fobi M, et al. Band erosion: Incidence, etiology, management and outcome after banded vertical gastric bypass. Obes Surg. 2001;11(6):699-707.
10. Ziegler O, et al. Medical follow up after bariatric surgery: nutritional and drug issues. General recommendations for the prevention and treatment of nutritional deficiencies. Diabetes Metab. 2009;35(6 Pt 2):544-557.
Rachel Weaver, APRN, MS, ANP-BC, CNE, and Catherine Hill, DNP, GNP
Rachel Weaver is a nurse practitioner at Memorial Hermann Health System in Houston and Tomagwa Healthcare Ministries in Tomball, Texas. Catherine Hill is a nurse practitioner at Dallas Institute of Health Sciences at Texas Woman's University.