Multidisciplinary team recommended for care after bariatric surgery

Heber D. J Clin Endocrinol Metab. 2010:95;4823-4843.

Issue: January 2011

The Endocrine Society recently released a clinical practice guideline that highlights the need for endocrine and nutritional management of patients after bariatric surgery, including those with diabetes.

The guideline was created by a task force that was chaired by David Heber, MD, PhD, professor of medicine and director of the University of California, Los Angeles, Center for Human Nutrition. The focus of the guideline is on the postoperative period and long-term management after surgery.

“Given the large number of people undergoing bariatric surgery, it is important for endocrinologists and primary care physicians to be knowledgeable about the postoperative care of these patients,” Heber told Endocrine Today. “The patients have a risk for weight regain if they do not participate in ongoing dietary and behavioral care in the long term.”

A team-based approach

Heber said the number of people undergoing bariatric surgery has increased within the past 2 decades, and the surgery has evolved with new technology that makes surgery less invasive and easier. However, with the newer laparoscopic procedures, the incidence of weight regain after surgery is higher than with traditional gastric bypass surgeries.

“One of the key recommendations in the guideline is the need for a multidisciplinary team to oversee the ongoing dietary needs of patients after surgery,” Heber said. “This should not be done by the surgeons alone. The team should include psychologists, nutritionists and endocrinologists to evaluate patients, as many patients present with different problems.”

The first recommendation is for the multidisciplinary approach to include diet instruction, increased activity, behavior modification and pharmacological therapy. In cases of severe weight gain, the team should consider a variety of options, including a possible revision surgery.

Postprocedure nutrition, monitoring

The guideline also recommends that patients take in 60 g to 120 g of protein per day and receive vitamin and mineral supplementation, especially those who underwent a malabsorptive procedure such as Roux-en-Y gastric bypass. Heber said those patients will require lifelong vitamin B12 replacements, as well as supplements of vitamin D and calcium, to promote bone health.

Patients should undergo routine biochemical monitoring to determine whether there are any micro- or macro-nutritional deficiencies. This monitoring should include glucose, creatinine and electrolytes for all patients. Those who had a Roux-en-Y gastric bypass, biliopancreatic diversion or duodenal switch should also be monitored for iron, vitamin B12, folate and calcium, among others.

When monitoring patients who have type 2 diabetes the task force recommended that patients’ HbA1c be 7% or less, with a fasting glucose of no more than 110 mg/dL. They also suggested that physicians and floor nurses be familiar with glycemic targets and the use of dextrose-free IV fluids and low-sugar supplements. Patients with type 1 diabetes should receive insulin during their hospital stay. Also, lipid-lowering therapy should be continued after surgery until levels reach the desired goals.

“None of these bariatric procedures are a cure for obesity,” Heber said. “They are a tool to help people with severe obesity deal with the disease. These patients must continue to have nutritional guidance for the rest of their lives.” – by Emily Shafer

Disclosure: Dr. Heber has no direct financial interest in any of the products mentioned in this article nor is he a paid consultant for any companies mentioned.

Nutritional complications related to bariatric surgery can occur years post-surgery. Most surgeons do not follow their post-operative patients that long, and many of these patients may have no primary care. These guidelines should be a ‘must read’ for primary care providers and emergency department physicians. When a patient with a remote history of a Roux-en-Y gastric bypass presents with vague complaints of fatigue, pain, weakness, etc., a red flag needs to go up. Providers need to consider these rare nutrient deficiencies in post-bariatric surgery patients.

– Brent Wisse, MD
Associate Professor, Diabetes & Obesity Center of Excellence,
University of Washington

Disclosure: Dr. Wisse has no direct financial interest in any of the products mentioned in this article nor is he a paid consultant for any companies mentioned.

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