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Provider Information Regarding Long-Term Medical Issues Related to Bariatric Surgery

Important Considerations of Bariatric Surgery
As a bariatric surgeon, I understand that certain obesity treatments performed have long-term medical consequences. I also understand that in this era of ever-expanding medical knowledge, it is difficult for every provider our patient interacts with to be an expert in long-term post-surgery care for the bariatric patient. This information has been developed in order to assist mutual providers in developing optimum care plans for postoperative weight loss surgery patients.

 
Symptom Considerations

  • Abdominal pain in these patients can be vague and misleading. Symptoms that should be managed in conjunction with a bariatric surgeon include:
    • Fever
    • Tachycardia
    • Shoulder pain
    • Recurrent cramping pain in the upper abdomen
    • Disproportionate abdominal tenderness or pain
    • Shortness of breath (symptom of pulmonary embolism)
    • Vomiting
    • Dry heaves
    • Bloating with hiccups
    • Pain out of proportion to exam
    • Inability to tolerate liquids for 24 hours
    • Dehydration is a common problem in the first several weeks following gastric bypass.

      Note: Lower abdominal cramping is usually associated with constipation and can be confirmed with a KUB.  Patients are encouraged to drink more water, as cramping often results from dehydration.

Medication Considerations

  • Extended-release and controlled-release medications may not be properly absorbed, and it is advised that patients be switched to a more immediate release formulation.
  • NSAIDS (including aspirin and COX-2 inhibitors) should be used only when medically necessary. These medications should be given in liquid form and in conjunction with a proton pump inhibitor (PPI) and/or cytotec. There is an increased risk of gastric ulcerations in these patients.
  • Bisphosphonates should not be used in this patient population due to the increased risk of gastric ulcerations.
  • Diuretics should be discontinued for at least one month after weight loss surgery because of high risk of significant dehydration.
  • Oral hypoglycemics and long-acting insulin preparations should be used with extreme caution and close monitoring in postoperative diabetic patients (except for type I diabetes), if at all, due to abrupt changes in insulin sensitivity and clinically significant hypoglycemia even within the first week postoperatively.
  • Calcium citrate is the required calcium replacement, as other calcium preparations aren’t adequately absorbed.
  • Potassium supplementation, if required, should be given in liquid form.
  • Pill size should be considered, as large pills may get stuck in the stomach pouch and cause ulceration.
  • Psychiatric medications may require increased doses due to alterations in absorption.
  • Anticoagulant medication: Absorption is variable and all medications need to be monitored very carefully. Coumadin absorption is unreliable and dosing will change as weight decreases. The patient has been asked to follow up with you as soon as possible.

Metabolic Considerations

  • Roux-en-Y Gastric Bypass surgery patients are at risk for micronutrient deficiencies (B12, Folate, Iron, Vitamin D, Calcium) ·          
    • Patients must be on a multivitamin (with 100% of all B-vitamins), sublingual or SQ B12, and calcium supplementation (at least 1,200 mg/day of calcium citrate plus D) for the remainder of their lives.
  • Iron-deficiency anemia is more common in these patients, particularly in menstruating women with concomitant menorrhagia. 
    • Patients can usually be treated with oral iron supplementation, but occasionally require iron infusions.
  • Bone turnover is known to be increased and bone mass is known to decrease, though long-term outcomes are unknown.  Yearly DEXA scans are recommended.
  • Secondary hyperparathyroidism may develop because of poor calcium uptake.
  • Protein deficiency can occur.  Intake of 60 gm. of protein per day is recommended.

Pregnancy

  • Our female patients are advised to wait at least 18 months postoperatively before attempting to conceive.
  • Should a patient become pregnant, it is important that she follow up immediately with our office, as there is a specific protocol she should follow.
  • Mechanical means of birth control, in addition to oral contraceptives, are recommended.
  • In patients with PCOS and/or infertility issues, significant weight loss following gastric bypass usually leads to increase in fertility (fertility drugs should be withheld until it is clear that infertility still exists).

Long-Term Follow-up

  • Patients in our program have labs drawn and studies done according to the following schedule postoperatively: one week-CBC, BMP; one month-CBC, CMP, Hgb.A1c (in diabetics); three months-CBC, CMP, Iron studies (serum iron, TIBC, ferritin), B12, Folate, Uric acid, Hgb.A1c, Lipid panel, TSH (with hypothyroidism), Vitamin A-D-E-K levels; six to nine months-Sleep study for patients on CPAP or BIPAP, Sleep study or PFT’s for those with sleep apnea not on CPAP; one year-CBC, CMP, Lipid panel, Uric acid, Folate, B12, Iron studies, Vitamins D and K, INR, TSH (with hypothyroidism), PTH, and Dexa scan.  Clinical findings will determine need for studies at other times or other studies.    
  • After the second year, annual monitoring is strongly recommended and should include weight, BMI, CBC, Iron studies, Albumin, Folate, B12, PTH, fat-soluble vitamins, INR, and DEXA scans.
  • Patients with Obstructive Sleep Apnea should stay on CPAP. Repeat sleep studies should be completed six months to nine months after weight loss surgery in order to determine if the CPAP needs to be adjusted or discontinued.

Patients are scheduled for follow-up visits in our program according to the following schedule: one week, one month, three months, six months, one year, eighteen months, two years, and yearly thereafter.