Post Bariatric Surgery Monitoring

Overview

Patients who have had Bariatric Surgery carried out under the NHS have follow up within specialist services for the first 1-2 years post surgery.

These guidelines are aimed at all non-specialist clinicians, dietitians and nurses to aid management of these patients once they are discharged back to primary care and aid management of any patients where follow up guidance by the surgical team was not issued.

Please note that patients who have moved area or who undergo a private procedure are likely to have had less specialist follow up and may need to be managed in primary care earlier, post procedure.

Guidelines for GPs

The British Obesity and Metabolic Surgery Society (BOMSS) has a GP hub (1)  with links to various resources including:

• Post-Bariatric Nutritional Guidance for GPs.
• Management of Complications following Bariatric Surgery
• Overview of GP management of Post- Bariatric patients
• Guidance on medications post bariatric surgery for GPs
• Statement on going abroad for weight loss surgery

Ten top tips for the management of patients post bariatric surgery in primary care

1. Keep a register of bariatric surgery patients and record the type of procedure in the register. Please note that follow up varies according to the type of surgery.

2. Encourage patients to check their own weight regularly and to attend an annual BMI and diet review with a health professional.

3. Symptoms of continuous vomiting, dysphagia, intestinal obstruction (gastric bypass) or severe abdominal pain require emergency admission under the local surgical team.

4. Continue to review co-morbidities post surgery such as diabetes mellitus, hypertension, hypercholesterolaemia and sleep apnoea as well as mental health.

5. Review the patient’s regular medications. The formulations may need adjusting post-surgery to allow for changes in bio-availability post surgery.

6. Bariatric surgery patients require lifelong annual monitoring blood tests, including micronutrients. Encourage patients to attend for their annual blood tests.(See guidance in the section below)

7. Be aware of potential nutritional deficiencies that may occur and their signs and symptoms. In particular, patients are at risk from anaemia and vitamin D deficiency as well as protein malnutrition and other vitamin and micronutrient deficiencies. If a patient is deficient in one nutrient, then screen for other deficiencies too.

8. Ensure the patient is taking the appropriate lifelong nutritional supplements required post surgery as recommended by the bariatric centre. Ensure guidance regarding vitamin supplementation has been issued by the bariatric surgery team. Request a copy for the patient’s GP records if this has not been included in the discharge information. (Also see information in the section below.

9. Discuss contraception – ideally pregnancy should be avoided for at least 12-18 months post surgery.

10. If a patient should plan or wish to become pregnant after bariatric surgery alter their nutritional supplements to one suitable during pregnancy. Inform the local bariatric unit of patient’s pregnancy and the obstetric team of the patient’s history of bariatric surgery.

Source: RCGP Ten top tips for the management of patients post bariatric surgery in primary care on the BOMSS Website Clinical Resources (bomss.org)

Specific guidance

Please see the vitamin and mineral recommendations and the blood test monitoring required in the attachments below, based on the type of surgery the patient has had. These have been developed by NBT Bariatric Dieticians.

(BOMSS) Nutritional guidance 2020 - Sleeve Gastrectomy and Roux-en-Y Gastric Bypass

(BOMSS) Nutritional guidance 2020 - Adjustable Gastric Band

Please check that the patient is taking the nutritional supplements as recommended in the guidance - non-adherence to supplements can often be the reason for deficiencies.

Blood testing is generally required annually but see the attachments for full details. Profiles have been created on both NBT and UHBW ICE systems to help GPs select the correct blood tests. There are two panels as testing is slightly different based on which procedure has been performed (either Sleeve Gastrectomy and Roux-en-Y Gastric Bypass or Gastric Band). 

NBT patients 

Should you require advice about abnormal bariatric nutritional blood test results, the Bariatric Dietitians can be contacted on: BariatricAdmin@nbt.nhs.uk. This is not a formal advice and guidance service, and timescales for when the query will be answered cannot be guaranteed. 

Please note that the dietitians are only able to answer queries about former NHS patients who underwent bariatric surgery at North Bristol NHS Trust. 

Non- NBT patients

For other patients who have had surgery done privately or elsewhere, please consider contacting the service which performed their operation for their advice if possible.

If you still require advice and guidance but cannot access it please let us know via the Feedback button (top right of this page) so that we can assess the scale of the issue.

Referral

Referral to NBT weight management services should not be required for monitoring so please use the guidance above. Should more intensive follow up be required, re-referral can be considered but further funding would need to be established.   

Acute complications

Patients that have had bariatric surgery and experience an emergency issue should be assessed as for any other emergency patient and referred through the surgical or medical take, if required, to assess the underlying issue. 

Non-acute complications

If a patient presents with non- acute abdominal symptoms following bariatric surgery, then they should be investigated and managed in primary care initially.  You can also request GI Advice & Guidance and refer if appropriate.

Resources

(1) BOMSS GP hub: https://bomss.org/gp-hub/

(2) Gastrectomy - Complications - NHS (www.nhs.uk) - patient information including advice on diet, dumping syndrome, vomiting and diarrhoea in patients who have had gastric surgery.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.