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Endocrine Society guidelines tackle post-bariatric surgery management
The Endocrine Society published a set of recommendations to guide clinicians in the short-term and long-term management of patients who have undergone bariatric surgery. The document includes guidelines for nutrition, endocrine measures and weight management strategies in multiple patient populations, including those with diabetes.
It is recommended that a technically proficient surgical team should be available to provide instructions for postoperative and long-term dietary modification and behavior modification. The task force suggests that it would be preferable for the support team to be certified by a nationally accredited organization.
When weight gain is severe or unremitting, the team should determine whether the gastrointestinal tract remains anatomically intact after surgical manipulation. If this is not the case, the team should consider multiple weight-loss options, including patient education or revisionary surgery.
Patients should consume an average of 60 g to 120 g protein per day to maintain lean body mass, according to the task force. This is particularly important for patients who have undergone malabsorptive procedures. Long-term vitamin and mineral supplementation are recommended in all patients, whereas periodic clinical and biochemical monitoring are recommended in certain patient populations. Clinicians are encouraged to view the full document for complete nutritional recommendations.
Patients with diabetes should maintain HbA1c of 7% or less, fasting blood glucose ≤110 mg/dL and postprandial glucose ≤180 mg/dL, according to the recommendations. Obese patients should receive insulin while in the hospital. Physicians and floor nurses should understand glycemic control targets and insulin protocols along with other barometers of diabetes control such as lipid abnormalities and cholesterol levels.
Malabsorptive procedures are defined as Roux-en-Y gastric bypass, gastric sleeve and biliopancreatic diversion. In patients undergoing these procedures, vitamin D, calcium, phosphorus, parathyroid hormone and alkaline phosphatase levels should be followed every 6 months, according to the task force. These patients also should receive a yearly DXA test for bone density.
Prophylactic therapy is recommended for postoperative patients who experience frequent attacks of gout.
In the immediate postoperative setting, patients should sip fluids, and only be released when they can satisfactorily tolerate oral fluids, according to the recommendations. A gradual progression of food consistency is recommended over weeks and months, particularly among patients receiving procedures with a gastric restrictive component.
The investigators warned that solutions with >100 g/day to 200 g/day of dextrose should be used with caution, and that calcium doses of 300 mg to 600 mg may inhibit iron absorption.
The recommendations are graded with regard to quality of supporting evidence and strength of recommendation. Clinicians are strongly encouraged to view the full document for these delineations for each point.
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