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Provider Information Regarding Long-Term Medical Issues Related to Bariatric Surgery

Symptom Considerations

• Abdominal pain in these patients can be vague and misleading. Symptoms that should be managed in conjunction with a Bariatric surgeon include:
  
  
  • Fever
  • Tachycardia
  • Shoulder pain
  • Recurrent cramping pain in the upper abdomen
  • Disproportionate abdominal tenderness or pain
  • Shortness of breath (symptom of pulmonary embolism
  • Vomiting
  • Dry heaves
  • Bloating with hiccups
  • Pain out of proportion to exam
  • Inability to tolerate liquids for 24 hours

  Dehydration is a common problem in the first several weeks following gastric bypass.

  Often, the first and most revealing diagnostic test for post bypass abdominal pain is a CT scan of the abdomen and pelvis to rule out the possibility of a closed loop afferent limb obstruction, signaled by unremitting nausea, non-productive vomiting, and a constant upper abdominal fullness and tenderness. This is usually due to adhesions or even an internal hernia.

  Afferent Limb Obstruction is a SURGICAL EMERGENCY and requires immediate operation to prevent necrosis and rupture of the distal gastric remnant.

  Note: Lower abdominal cramping is usually associated with constipation and can be confirmed with a KUB. Patients are encouraged to drink more water, as cramping often results from dehydration.

Medication Considerations

• Extended-release and controlled-release medications may not be properly absorbed, and it is advised that patients be switched to a more immediate release formulation.
• NSAIDS (including aspirin and COX-2 inhibitors) should be used only when medically necessary. These medications should be given in liquid form and in conjunction with a proton pump inhibitor (PPI) and/or cytotec. There is an increased risk of gastric ulcerations in these patients.
• Bisphosphonates should not be used in this patient population due to the increased risk of gastric ulcerations.
• Diuretics should be discontinued for at least one month after surgery because of high risk of significant dehydration.
• Oral hypoglycemics and long-acting insulin preparations should be used with extreme caution, if at all, and close monitoring is needed in postoperative diabetic patients (except for type I diabetes), due to abrupt changes in insulin sensitivity and clinically significant hypoglycemia even within the first week postoperatively.
• Calcium citrate is the required calcium replacement, as other calcium preparations aren’t adequately absorbed in patients taking acid reducing medications.
• Potassium supplementation, if required, should be given in liquid form.
• Pill size should be considered, as large pills may get stuck in the stomach pouch and cause ulceration.
• Psychiatric medications may require increased doses due to alterations in absorption.
• Anticoagulant medication: Absorption is variable and all medications need to be monitored very carefully. Coumadin absorption is unreliable and dosing will change as weight decreases. The patient has been asked to follow up with you as soon as possible.

Metabolic Considerations

• Roux-en-Y Gastric Bypass patients are at risk for micronutrient deficiencies (B12, Folate, Iron, Vitamin D, Calcium)
  • Patients must be on a multivitamin (with 100% of all B-vitamins) B12 injections 1cc IM (1000 mcg) q-month, and calcium supplementation (at least 1,000 mg/day of calcium citrate plus D) for the remainder of their lives.
• Iron-deficiency anemia is more common in these patients, particularly in menstruating women with concomitant menorrhagia.
  • Patients can usually be treated with oral iron supplementation, (Iron needs to be a (gluconate or furmerate form, since the absorption of sulfate preparations require the presence of acid). Occasionally patients require iron infusions.
• Bone turnover is known to be increased and bone mass is known to decrease, though long-term outcomes are unknown. Yearly DEXA scans are recommended.
• Secondary hyperparathyroidism may develop because of poor calcium uptake.
• Protein deficiency can occur. Intake of a minimum of 65 gm. of protein per day is recommended.

Pregnancy

• Our female patients are advised to wait at least 18 months postoperatively before attempting to conceive.
• Should a patient become pregnant, it is important that she follow up immediately with our office, as there is a specific protocol she should follow.
• Mechanical means of birth control, in addition to oral contraceptives, are recommended.
• In patients with PCOS and/or infertility issues, significant weight loss following gastric bypass usually leads to increase in fertility (fertility drugs should be withheld until it is clear that infertility still exists).

Long-Term Follow-up

• Patients who have had gastric bypass should have labs drawn and studies done according to the following schedule postoperatively: one week-CBC, BMP; one month-CBC, CMP, Hgb.A1c (in diabetics); three months-CBC, CMP, Iron studies (serum iron, TIBC, ferritin), B12, Folate, Uric acid, Hgb.A1c, Lipid panel, TSH (with hypothyroidism), Vitamin A-D-E-K levels; six to nine months-Sleep study for patients on CPAP or BIPAP, Sleep study or PFT’s for those with sleep apnea not on CPAP; one year-CBC, CMP, Lipid panel, Uric acid, Folate, B12, Iron studies, Vitamins D and K, INR, TSH (with hypothyroidism), PTH, and Dexa scan.
• Clinical findings will determine need for studies at other times or other studies.
• After the second year, annual monitoring is strongly recommended and should include weight, BMI, CBC, Iron studies, Albumin, Folate, B12, PTH, fat-soluble vitamins, INR, and DEXA scans.
• Patients with Obstructive Sleep Apnea should stay on CPAP. Repeat sleep studies should be completed six months to nine months after surgery in order to determine if the CPAP needs to be adjusted or discontinued.

Patients are scheduled for follow-up visits in our program according to the following schedule: one week, Two weeks, and once a month for the first year. Every three months the second year, every six months the third year and yearly thereafter.

At each visit, they are questioned about their contact with you, and about any changes to their medications. They are actively encouraged to seek your advice and care for all other health-related matters, e.g. the scheduling of mammograms, etc.

This schedule is not meant to supplant their need for follow-up with you, as we normally will not draw blood or order lab tests except for acute issues. We merely want to make sure that they are using their tool properly and weight loss is progressing as anticipated. We do take this opportunity to administer B12 shots.

We try to supplement, rather than supplant your care, in the hope that you will consider us for other, non-weight related general surgical care, as we offer a full range of General Surgery services.

Thank you for your support and we look forward to being able to be of continued service to you and your patients.

William J. Roe, Jr., M.D., F.A.C.S. and Staff