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To our referring providers, we hope that the information that we post on this page will serve as helpful resources and tools in helping your patients to make their decision to pursue weight loss surgery.
As the primary care physician, referring provider, and/or another member of a patient´s care-team, we hope that the information below will provide you with a better understanding of our post-operative process and how you can help your patients with their continuum of care. Our team is always available to help you with any questions or concerns that you may have, so please do not hesitate to contact us.
Important Considerations of Bariatric Surgery
As a bariatric surgery program, we understand that certain obesity treatments performed have long-term medical consequences. We 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 any patient with a gastric bypass, sleeve or laparoscopic adjustable gastric band 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.
If our patients experience any of these symptoms, do not hesitate to call us so that we can be involved early should our patients have any problems.
- 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 early post op.
- 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. Early post operation we recommend crushing all pills that can be crushed or use liquid formulation.
- 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.
- 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 60-80 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).
Patients in our program have labs drawn and studies done according to the following schedule postoperatively: one week-CBC, BMP; one month-CBC, CMP, 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, prealbumin; six to nine months-Sleep study for patients on CPAP or BIPAP, Sleep study 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, Thiamine, 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. Follow up visits are important to monitor compliance with medication and lifestyle modification.
In general, band patients are at less risk for serious perioperative complications than the gastric bypass patients. However, there are specific issues that can arise after the placement of the band that you may see. Band patients are typically seen every 4-6 weeks starting after surgery. This is necessary as the bands need close follow up and careful adjustment to achieve the early satiety and sustained hunger suppression with small meals. They also need to be carefully monitored for weight loss and development of maladaptive eating which may develop as patients try to eat past the band.
Patients frequently may complain of difficulty with solid foods after a band tightening. This is usually transient and the peak sensation is 2-3 days post adjustment as there is swelling of the stomach tissue after constricting it with the band fill.
After a band adjustment, the band may be too tight, though they can drink fluids. Patients may report significant heartburn, a sensation of something in the back of their throat, or a choking sensation if they were to lie down. In addition, they may report night time cough, or choking. At this point, weight loss is poor, as patients discover that while solids do not stay down, liquid calories such as ice cream and soups go down without difficulty. These patients should be encouraged to return to us for an adjustment.
Patients should always be able to drink water and thin liquids without feeling significant restriction. If there is too much swelling, and/or the patient has been vomiting, the patient may not even be able to tolerate water. This is not normal and the patient will need fluid removed from the band.
Overall risks of nutritional and metabolic complications are low, as there is no malabsorbtive component to the adjustable gastric banding. However, the patient is recommended take at least one multi-vitamin daily to avoid micronutrient deficiencies.
Less common but more significant is the development of slippage. This is literally the band sliding down lower on the stomach, and as it does it constricts more stomach and thicker stomach causing a complete obstruction. Here the vomiting is pronounced, profuse and unremitting with patient unable to even tolerate their own secretions. These patients may get relief with removal of fluid from the band, but usually will require going to the operating room for revision of the band to replace it in the correct position
Potential for DMII Cure After Surgery
Managing Medical and Surgical Diseases
| GBMC Physician Pavilion North • N. Charles Street, Suite 125 • Towson, MD 21204 • 443.849.3779 |
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