BARIATRIC SURGERY INFORMATION FOR GENERAL PRACTITIONERS

For patients who are struggling with obesity and have tried everything to lose weight, bariatric surgery can have positive health outcomes. This is especially true if patients have co-morbidities like diabetes, hypertension, heart disease or depression. In these instances, weight loss surgery can be a lifesaving solution. General Practitioners play a crucial part in deciding a patient’s suitability for surgery as well as supporting them on what will be a lifelong journey to wellness following their procedure. Importantly, GPs are also often on the frontline in dealing with any health issues which may arise for patients post-surgery. Below, we provide some handy information for General Practitioners considering referring a patient for weight loss surgery, as well as for those participating in their post-operative care.

Referral Information

Our approach to patient health and wellbeing

Weight Loss Solutions Sunshine Coast perform all types of surgeries including laparoscopic sleeve gastrectomy, laparoscopic gastric bypass, laparoscopic gastric band, and the non-surgical gastric balloon.

Both surgeons are highly experienced general laparoscopic and bariatric surgeons (FRACS) and operate together as a team on all patients. This level of expertise during surgery is reassuring for many patients and their GPs. It also provides continuous care as they are able to back each other up for leave. See more about our surgeons.

Regardless of the type of procedure the patient undergoes, weight loss surgery is a lifelong process. We believe that the most durable weight loss outcomes are achieved when all health practitioners are able to work together. Patients are offered comprehensive care and support with access to allied health professionals experienced in weight loss, including a dietitian, exercise physiologist and a psychologist.

Below is some comprehensive information for GPs for the primary care of bariatric patients.

With obesity figures rising year in year out, we know that GPs are seeing more patients who are considering or who have undergone bariatric surgery. Below is a guide to the different instances where a patient could be eligible for surgery. As well, we outline the nutritional screening requirements.

Surgery Eligibility Criteria

Australian & New Zealand Metabolic and Obesity Surgery Society recognise these suitability criteria:

1. Weight greater than 45kg above the ideal body weight for sex, and height;
2. BMI > 40 by itself or >35 if there is an associated obesity illness, such as diabetes or sleep apnoea;
3. Reasonable attempts at other weight loss techniques;
4. Age 18-65;
5. Obesity-related health problems;
6. No psychiatric or drug dependency problems. (In practice, this means that if psychological problems are present, these are being actively managed or controlled. A surgeon can confirm suitability in this regard);
7. A capacity to understand the risks and commitment associated with the surgery.

Note: Patients who fall outside these criteria may still be suitable for surgery. We recommend patients and GPs discuss individual circumstances with a surgeon to confirm suitability. 

Diabetes Mellitus Patients

Recently, the efficacy of bariatric surgery to reverse conditions like Diabetes Mellitus (DM) has been internationally recognised. It is now recommended for:

• all individuals with T2DM and BMI ≥40 kg/m2
• individuals with BMI 35–40 kg/m2 with inadequate glycaemic control despite lifestyle and optimal medical therapy.

Pre-Operative Screening

After we have determined suitability for surgery based on the above criteria, we will require further testing prior to the procedure.

Nutritional and Blood Screening

Blood tests (FBE, ELFT, TFT) should be performed prior to surgery, as well as random blood glucose, fasting cholesterol and triglycerides. Nutritional screening is also vital. The RACGP recognises that between 35% and 80% of bariatric candidates are “in a state of ‘high-calorie malnutrition’, and show some signs of dietary deficiency pre-operatively.”

Comprehensive screening should be performed in order to correct any deficits before surgery. In this way, we as surgeons can more effectively monitor nutrient levels postoperatively.

If you are seeing a patient who is considering surgery, it is always helpful if they have had pre-operative blood testing completed prior to their consultation. Below are the blood tests which would be required:

Medicare Coverage for Blood Tests

Generally, Medicare will cover pre-operative testing for a restricted number per year, and with malabsorption or bariatric surgery noted on the request form.

• 66607 Vitamins – quantitation of vitamins A or E in blood, urine or other body fluid – 1 or more tests within a 6 month period
  Fee: $75.75 Benefit: 75% = $56.85 85% = $64.40
• 66819 Quantitation of copper, manganese, selenium, or zinc (except if item 66667 applies), in blood, urine or other body fluid – 1 test. (Item is subject to rule 6, 22 and 25)
  Fee: $30.60 Benefit: 75% = $22.95 85% = $26.05
• 66822 Quantitation of copper, manganese, selenium, or zinc (except if item 66667 applies), in blood, urine or other body fluid – 2 or more tests. (Item is subject to rule 6, 22 and 25)

Dietary Assessment

Nutritional screening should also go hand in hand with an assessment by a bariatric accredited practising dietitian (APD). We have access to a Sunshine Coast APD who can assess patients across the Sunshine Coast. A dietitian can identify any other issues which may affect the patient’s nutritional status pre and post-surgery.

Other Tests

There are also other tests which we may require:

• Oral glucose tolerance test if necessary to determine DM diagnosis.
• ECG – cardiologist referral may be necessary prior to surgery.
• Pre-op contrast swallow, or an endoscopy.
• A sleep study may also be required.

Preparation for surgery

Usually 2–4 weeks prior to surgery we ask patients to follow a very low energy diet (VLED) where possible. We recommend our patients follow a very low carb diet at this time. The diet is designed to reduce the size of the liver, assisting in a safer and more effective operation. This diet is undergone with the guidance of an APD according to patient nutritional requirements. In the diabetic patient, we must also carefully monitor blood glucose and medication, to reduce the risk of hypoglycaemia.

To ensure optimal healing following surgery, the patient is asked to follow a liquid diet initially. The texture progression from solid to liquid food will depend on the individual procedure, as well as the patient’s own tolerance level. Lapband patients may have transitioned to solid food by 5 weeks, however, for sleeve gastrectomy and gastric bypass, the transition to solid food may take up to 8 weeks to ensure adequate healing time. During this time, our primary emphasis is on ensuring all patients remain hydrated, and that their uptake of protein and nutrients is sufficient.

Post-Operative Complications

Complications can arise following surgery. Most complications should be followed up by the patient’s surgeon post-operation. Importantly what is fairly routine following one surgery can be potentially life-threatening with another surgery. How do you know what symptoms require further investigation? Here is an outline of what ISN’T normal following bariatric surgery. If ever unsure, you are encouraged to call us, we are always happy to discuss any patient concerns over the phone with you.

Emergency Complications Days and Weeks Post Surgery

PATIENT SYMPTOMS REQUIRING EMERGENCY REFERRAL IN THE DAYS AND WEEKS POST-SURGERY

• Pyrexia
• Tachycardia
• Abdominal pain
• Chest pain
• Repetitive vomiting and epigastric pain (gastric band, gastric sleeve)
• Repetitive vomiting and/or dysphagia (gastric bypass)
• Breathlessness
• Frank wound infection (gastric band)
• Clinical bowel obstruction at any time (gastric bypass)

Abdominal Pain

Recurrent abdominal pain in any patient in the days or weeks following surgery requires an emergency investigation by surgeons. As months pass after surgery, some intermittent abdominal pain may be routine in gastric sleeve patients. However, this should still be referred for further follow-up. Intermittent abdominal pain in the months and even years following gastric bypass is considered an urgent issue and can in some cases be an emergency.

Nausea, Vomiting or Heartburn

In both gastric band and gastric sleeve patients, heartburn can occur. This complication should be referred for further investigation relatively urgently. Gastric band patients may also experience night time coughing and intermittent vomiting, which should be considered an urgent referral. Gastric sleeve patients may occasionally experience vomiting but a routine investigation by a surgeon is advised.

Pregnancy

When a patient becomes pregnant post-surgery, it is advisable to refer them back for follow-up care as early in the pregnancy as possible. This applies even years after their surgery.

Poor Weight Loss and Weight Regain

Weight regain in the years after a procedure can occur. Poor weight loss is more common in the gastric band patient but can occur with any procedure. A routine referral for examination is advisable.

Medication and Supplements

The post-surgery patient has new medication requirements. A review should be undertaken of all medication periodically. It is advised that patients avoid nonsteroidal anti-inflammatory drugs. It is also advised that antihypertensives and lipid medications be adjusted where required, but shouldn’t be discontinued without careful consideration. Anti-diabetes medications may also be adjusted. In many cases, diabetes will go into remission. The bariatric patient also has new nutritional needs, which they will have for life.

The general requirements are:

• Adult multivitamin and multimineral – containing iron, folic acid, thiamine, vitamin B12. Doses: two daily for sleeve gastrectomy or Roux-en-Y gastric bypass; one daily for adjustable gastric band
• Citrated calcium – elemental calcium 1200–1500 mg/day
• Vitamin D – titrate to 25-OH vitamin D levels >30 ng/mL. Typical dose required 3000 IU/day
• Additional iron and vitamin B12 supplementation as required, based on lab results

RACGP website The Bariatric Surgery Patient

What to do with patients lost to follow up?

Bariatric surgery requires life-long follow up for better weight loss outcomes and in order to recognise any complications should they arise. Patients who are not on a follow-up care program, or who have missed appointments should be encouraged to return to follow-up. A schedule of three, six and twelve-month follow-up visits is advised. A patient who is lost to follow up may not see the best results from their surgery, regardless of how well it was performed. You may wish to refer the patient to another bariatric surgeon to continue care if they:

• had their procedure with a facility which doesn’t provide a follow-up program;
• were unhappy with the care they received from their surgeon;
• have recently moved to a new area.

Patients do best when they are dedicated, and follow-up care helps to ensure enduring commitment to weight loss and health.

Further reading

• http://www.bomss.org.uk/primary-care-management-of-post-operative-patients/
• http://www.racgp.org.au/afp/2013/august/the-bariatric-surgery-patient/
• http://www.racgp.org.au/afp/2017/july/bariatric%E2%80%93metabolic-surgery-a-guide-for-the-primary-care-physician/