Primary Care Treatment of Patients Following Bariatric Surgery in 2020
Bariatric surgery is commonly suggested for achieving weight loss in unmanageable obesity. Quality of clinical care after surgery plays an important role in treatment outcomes. Chen and colleagues (2020) published a guideline titled “Primary Care Treatment of Patients Following Bariatric Surgery in 2020” published in JAMA Network Open. The summary of this guideline is given below:
Objective:
To provide management guidelines for common bariatric complications.
Method:
The list of common complications and managemental guidelines was developed from the currently available evidence and scientific and medical knowledge.
Guidelines:
Assessment for every clinical visit- Weight loss, Level of exercise, Vitamin and mineral supplementation being taken, Comorbidity assessment (type 2 diabetes, hypertension, sleep apnea, joint pain), and Potential bariatric surgery complications.
Annual laboratory assessment: Complete blood cell count, complete metabolic panel, Vitamin B1, Hemoglobin A1c, Thyroid-stimulating hormone, Lipid evaluation based on risks, Folate, iron studies, 25-hydroxyvitamin D, and zinc for Roux-en-Y gastric bypass surgery and Other vitamin laboratory measurement if deficiency is suspected.
1) Complication: Gastroesophageal Reflux Disease (GERD)
Presentation: Heartburn, chest pain, and nausea
Diagnosis: Clinical diagnosis; esophagogastroduodenoscopy (EGD) only indicated for severe symptom
Management: proton pump inhibitor (PPI) therapy; conversion to Roux-en-Y gastric bypass surgery (RYGB) for severe GERD refractory to PPI treatment
2) Complication: Dumping syndrome
Presentation: Colicky abdominal pain, diarrhoea, nausea, and tachycardia
Diagnosis: Clinical diagnosis; blood glucose level
Management: Avoid food with high simple sugar content and replace with high-fibre, complex carbohydrate, and high-protein food; acarbose
3) Complication: Cholelithiasis
Presentation: Right upper quadrant pain if symptomatic
Diagnosis: Abdominal ultrasonography
Management: Cholecystectomy for symptomatic cholelithiasis (approximately 10% of patients may need cholecystectomy after bariatric surgery)
4) Complication: Marginal ulcer
Presentation: Upper abdominal pain, nausea, and vomiting
Diagnosis: EGD
Management: Smoking cessation; avoid nonsteroidal anti-inflammatory drug (NSAIDs); PPI and Carafate; endoscopic or surgical procedures for refractory cases
5) Complication: Stricture of the anastomosis
Presentation: Dysphagia, nausea, and vomiting
Diagnosis: Upper gastrointestinal tract series; EGD
Management: Endoscopic dilation; surgical revision
6) Complication: Gastric banding complications
Presentation: Nausea, vomiting, and food intolerance; port site infection; and abdominal pain
Diagnosis: EGD; kidney, ureter, and bladder (KUB) radiographic imaging; computed tomographic imaging of the abdomen
Management: Band adjustment for the tight band; band revision or removal for slippage, erosion, or severe GERD; conversion to RYGB or, sleeve gastrectomy (SG) to prevent weight regain
7) Complication: Hypoglycemia
Presentation: Confusion, heart palpitation, shakiness, and excessive sweating
Diagnosis: Blood glucose and insulin level; continuous glucose monitoring
Management: Dietary counselling; high-protein, high-fibre, and low-carbohydrate diet; acarbose; gastric bypass reversal reserved for patients with refractory symptoms
8) Complication: Bowel obstruction/internal hernia
Presentation: Nausea, vomiting, and abdominal pain
Diagnosis: KUB radiographic imaging; computed tomographic imaging of the abdomen
Management: Low threshold for surgical exploration for unexplained abdominal pain after RYGB.
Image Credit: Woman photo created by peoplecreations – www.freepik.com