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
Follow-up Care
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.
Complications
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.
References
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.
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