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Mechanick et al. 2020 (same article as above, but located on AACE Endocrine Practice site)

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Clinical Practice Guidelines For The Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures – 2019 Update

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Clinical Practice Guidelines For The Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures – 2019 Update

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Abstract

Bariatric surgical patients often need changes in formulation and dosages of their medications. The literature contains minimal information regarding pharmaceutical care and consultation services for the bariatric surgery patient. Complex medication regimens and safety concerns initiated a collaborative effort between surgeons and pharmacists to manage more effectively bariatric patients perioperatively. The consultation service included patient identification, pharmacy referral, pharmacist consultation with the patient, communication of recommendations with surgeons, follow-up, and documentation. There were 124 consultations performed from February 2, 2009 to December 1, 2010 with an average of 7.7 medications optimized per patient. Every patient required a minimum of one adjustment to their regimen. The surgeons approved 98% of these recommendations. Of recommendations provided, the majority focused on changing the formulation of the medication in some manner. The collaborative effort between surgeons and pharmacists effected changes in medication transitioning perioperatively and resulted in improved pharmaceutical care for this patient population.

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Cited by

Drug absorption in bariatric surgery patients: A narrative review.

Alalwan AA, Friedman J, Alfayez O, Hartzema A. Alalwan AA, et al. Health Sci Rep. 2022 Apr 26;5(3):e605. doi: 10.1002/hsr2.605. eCollection 2022 May. Health Sci Rep. 2022. PMID: 35509385 Free PMC article. Review.

Impact of pharmacist interventions on drug-related problems in general surgery patients: a randomised controlled trial.

AbuRuz S, Jaber D, Basheti I, Sadeq A, Arafat M, AlAhmad M, Said A. AbuRuz S, et al. Eur J Hosp Pharm. 2021 Nov;28(Suppl 2):e72-e78. doi: 10.1136/ejhpharm-2020-002206. Epub 2020 Jul 13. Eur J Hosp Pharm. 2021. PMID: 32661104 Free PMC article. Clinical Trial.

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national center for biotechnology information

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Bariatric surgery pharmacy consultation service - PubMed

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Bariatric surgical patients often need changes in formulation and dosages of their medications. The literature contains minimal information regarding pharmaceutical care and consultation services for the bariatric surgery patient. Complex medication regimens and safety concerns initiated a collabora ...

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© 2023 Pam Davis Consulting, LLC | Bariatric University

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Mobilizing the Patient with Obesity AvH edits

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Introduction

The CDC estimates 42.4% of U.S. adults had obesity and 9.2% had severe obesity in 2017, the highest incidence ever recorded in America (latest report), according to the Obesity in America Report published by the American Society for Metabolic and Bariatric Surgery (ASMBS). The comorbidities associated with obesity range from diabetes and heart disease to certain types of cancers. Metabolic/bariatric surgery is the most effective and durable treatment for severe obesity leading to significant weight loss and the improvement, prevention or resolution of many related diseases. For these reasons, the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP®) will recognize those facilities that implement defined standards of care, document their outcomes, and participate in regular reviews to evaluate their metabolic and bariatric surgical programs.

Overview

A highly visible and important issue facing the medical profession and the healthcare industry today is the quality of care provided to patients. Numerous stakeholders including providers, payors, and private industries have invested a large amount of resources in order to be able to measure, report, and improve clinical care.

MBSAQIP works to advance safe, high-quality care for metabolic and bariatric surgical patients through the accreditation of metabolic and bariatric surgical centers. A metabolic and bariatric surgical center achieves accreditation following a rigorous review process during which it proves that it can maintain certain physical resources, human resources, and standards of practice. All accredited centers report their outcomes to the MBSAQIP registry.

History

The American College of Surgeons (ACS) was founded in 1913 with the goal of improving surgical care and setting standards, and the current Joint Commission (JCAHO) grew out of the ACS Hospital Standards Committee in 1951. The ACS has been accrediting trauma programs through the Trauma Verification Program since 1987 and cancer programs through the Commission on Cancer since 1930. In 2005, in response to a growing need in the metabolic bariatric surgery community, the ACS released the first Bariatric Surgery Center Network (ACS BSCN) accreditation standards manual.

The American society for Metabolic and Bariatric Surgery (ASMBS), founded in 1983, was formed to advance the art and science of metabolic and bariatric surgery by continually improving the quality and safety of care and treatment of people with obesity and related diseases through educational and support programs for surgeons and integrated health professionals. The leadership of the ASMBS found it within their mission to release their own set of accreditation standards for Bariatric Surgery Centers of Excellence (BSCOE) in 2004, creating two separate but similar accrediting bodies for bariatric surgery.

Both programs focused on three key principles: the leadership of surgeons, the necessity for a multidisciplinary team, and the reporting of outcomes to a national registry. Accreditation was based on procedure volume, as well as other structural and process measures that provided a framework for facilities performing these types of procedures. Even discounting the impact of the introduction of laparoscopy (a change from 2.1 percent in 1998 to more than 90 percent in 2008) and inclusion in the data of the adjustable gastric band (less 30 day mortality and morbidity), the adoption of accreditation standards led to a remarkable decrease in mortality from one in 200 patients to one in 1,750 patients. The majority of centers offering bariatric surgery programs in the United States participated in one of the former two accreditation programs. The data registries for both of the accreditation programs were under development in 2006 and in 2011 had more than 100,000 patients per year being entered into one of the two registries.

Transition to the MBSAQIP

The American College of Surgeons (ACS) and the American Society for Metabolic and Bariatric Surgery (ASMBS) combined their respective national bariatric surgery accreditation programs into a single unified program to achieve one national accreditation standard for bariatric surgery centers, the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP®).

On March 9, 2012, the ACS signed a memorandum of understanding with the ASMBS to unify their respective bariatric surgery center accreditation programs. As of April 1, 2012, all institutions that met the standards under the two separate programs-the ACS BSCN program and the ASMBS BSCOE program-were extended accreditation in the joint MBSAQIP. The new, joint program is administered by the staff and committees of the ACS, and all centers now submit data to the existing ACS bariatric data registry.

MBSAQIP works to advance safe, high-quality care for bariatric surgical patients through the accreditation of bariatric surgical centers. A bariatric surgical center achieves accreditation following a rigorous review process during which it proves that it can maintain certain physical resources, human resources, and standards of practice. All accredited centers report their outcomes to the MBSAQIP registry.

How It Works

MBSAQIP collects data on preoperative risk factors, preoperative laboratory values, intraoperative variables, 30-day postoperative mortality and morbidity on all patients undergoing metabolic and bariatric procedures which meet program criteria. Long term data is collected for patients as well. Data are collected by highly trained and certified Metabolic and Bariatric Surgical Clinical Reviewers (MBSCRs), who enter the data into a secure internet website. After the data is entered, it is available to be viewed by a center continuously, and this data is risk-adjusted by MBSAQIP on a bi-annual basis. After thorough cleaning, the data is analyzed and odds ratios (ORs) are produced for each participating facility in bi-annual reports. An OR greater than 1 indicates that the center is experiencing more postoperative outcomes than expected. Conversely, an OR less than 1 indicates that the center is having better results than expected based on its patient characteristics and the complexity of the procedures performed. Bi-annually, detailed reports with ORs, statistical details, and hierarchical regression models are distributed to the participating centers. Centers with consistently low ORs are encouraged to share with the MBSAQIP the processes and structures that they consider to have contributed to their good performance.

Data Collection

At each participating center, a specially trained, dedicated MBSCR collects the preoperative, intraoperative, and postoperative outcome data on all cases that meet Program criteria. The MBSCR enters all collected data into the MBASQIP Data Registry. The data is then transmitted to MBSAQIP where (after performing data checks for valid data entry) the data is subjected to statistical analysis.

Risk-Adjustment

Risk-adjusted models for MBSAQIP participating centers are computed every 6 months, using data from the previous 12-month period (with a 6 month lag due to case locking and time required for the analysis) and are reported semi-annually in the Semi-annual Report (SAR). Risk-adjusted results are currently computed for Laparoscopic Sleeve Gastrectomy and Laparoscopic Roux-En-Y Gastric Bypass cases, including Morbidity, Reoperations, Interventions and Readmissions. Also included in the SAR are risk- adjusted results focusing on specific surgical occurrences. Risk adjustment is important because it takes into account differences in patient and procedure mix between centers, thus permitting fair comparisons of centers.

MBSAQIP modeling techniques have evolved and improved over time as new statistical techniques have become available. Our current risk-adjustment modeling process generally follows the below described process, though certain models might be approached somewhat differently.

Forward stepwise logistic regression is then used to develop a predictive model for each outcome. At the first step, the predictor that is most strongly associated with the outcome is selected. After that, correlations between all remaining unselected variables and the outcome are adjusted for predictors already in the model, and the variable with the next strongest association is entered. This continues until no remaining variable is capable of significantly improving the model. This process chooses a useful predictive set from 30 or more potential predictive variables.

The variables selected by the logistic regression are then used in a hierarchical model. One important advantage of hierarchical models, as we have implemented them, is that they are able to pool information about what is known about all centers with what is known about a specific center to achieve a best prediction about center quality. Particularly when the center sample size is small, thus pooling results in the center quality estimate being "shrunk" towards the mean of all centers. For technical reasons, the best center quality metric derived from a hierarchical model is the odds ratio.

The odds ratio is the ratio of odds (number of patients exhibiting the event/number of patients not exhibiting the event) for a target group to the odds for a comparison group. An odds ratio of 1.0 implies that the event is equally likely in both groups. An odds ratio greater than 1.0 implies that the event is more likely in the first group and an odds ratio less than 1.0 implies that the event is less likely in the first group. For example, an odds ratio of 1.5 for preoperative hypertension versus no preoperative hypertension, means that there is a 50% increase in odds for the event for patients with preoperative hypertension. For MBSAQIP hierarchical modeling, an odds ratio is also constructed for the effect of center on the outcome. For these odds ratios, the numerator is the odds for the center (where the "observed" number of events and number of non- events are adjusted by the statistical model) and the denominator is the average odds for all centers. If the odds ratio is equal to 1.0, the center is doing as expected. If the odds ratio is greater than 1.0, the center is doing worse than expected. If the odds ratio is less than 1.0, the center is doing better than expected.

Use of MBSAQIP for Quality Improvement

Bi-annually, the statistical results of the data are reported back to the participating centers for their review and utilization in quality improvement. This comprehensive report includes the ORs and the hierarchical regression models. These ORs provide an overview of the assessment of quality of care in the surgical service.

Additionally, a suite of continuously updated online reports are on the website for each center to use and review. These reports are currently utilized by the participating centers for early and on-going identification of areas for quality improvement.

Reliable Data

One of MBSAQIP's strengths is its capture of clinically rich data pursuant to MBSAQIP Standard 7.0, Continuous Quality Improvement. MBSAQIP assures the reliability of the data through a variety of means, such as detailed initial training, continuing education, data integrity audits, testing, monthly educational questions and ongoing conference calls. Participants in MBSAQIP have come to trust the reliability of the data and use the online reports in conjunction with the bi-annual reports to identify opportunities to improve processes and outcomes of surgical care.

MBSAQIP Surgeon Leadership

The MBSAQIP surgeon committee structure consists of an overarching advisory committee and two subcommittees. The Committee for Metabolic and Bariatric Surgery (CMBS) serves to better the care and welfare of obese patients through outreach, standards development, outcomes assessment, measures development and endorsement, continuing education, and the creation of national quality initiatives. Two subcommittees of the CMBS support the program:

Standards and Verification Subcommittee is responsible for the development and maintenance of accreditation standards by validation and certification that each individual center meets accreditation criteria.

Data and Quality Subcommittee is responsible for the data registry and provides input on analytical and reporting tools to support the needs of the program. This subcommittee also develops initiatives related to quality improvement, collaborative work, and support of metabolic and bariatric surgical directors in leadership of their centers.

About this Operations Manual

This operations manual is intended to provide detailed guidelines for the MBSCR to assess cases and collect data for the MBSAQIP. While not all questions can be answered within a single source, this manual is a compendium of years of experience with MBSAQIP. Questions not answered in this source should be addressed with the Clinical Support Team. We hope that you find this manual a useful reference to guide your practice and we welcome feedback for future improvements.

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The CDC estimates 42.4% of U.S. adults had obesity and 9.2% had severe obesity in 2017, the highest incidence ever recorded in America (latest report), according to the Obesity in America Report published by the American Society for Metabolic and Bariatric Surgery (ASMBS).

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1. Approve of the disclaimer
2. Select "Weight IAT"

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Preliminary Information

On the next page you'll be asked to select an Implicit Association Test (IAT) from a list of possible topics . We will also ask you (optionally) to report your attitudes or beliefs about these topics and provide some information about yourself.

We ask these questions because the IAT can be more valuable if you also describe your own self-understanding of the attitude or stereotype that the IAT measures. We would also like to compare differences between people and groups.

On the IAT, you may find it easier to pair certain attributes with one group of people compared to another. Your IAT results may depart from your personal beliefs.

Note: This site is designed for adults, aged 18 or older.

Data Privacy: Data exchanged with this site are protected by SSL encryption. Project Implicit uses the same secure hypertext transfer protocol (HTTPS) that banks use to securely transfer credit card information. This provides strong security for data transfer to and from our website. IP addresses are routinely recorded, but are completely confidential. For research purposes, data without directly identifying information is made publicly available. You can find more information on our Data Privacy page.

Important disclaimer: In reporting to you results of any IAT test that you take, we will mention possible interpretations that have a basis in research done (at the University of Washington, University of Virginia, Harvard University, and Yale University) with these tests. However, these Universities, as well as the individual researchers who have contributed to this site, make no claim for the validity of these suggested interpretations. If you are unprepared to encounter interpretations that you might find objectionable, please do not proceed further. You may prefer to examine general information about the IAT before deciding whether or not to proceed.

If you have questions about the study, please contact Project Implicit at questions@projectimplicit.net. To obtain more information about the study, ask questions about the research procedures, express concerns about your participation, or report illness, injury or other problems, please contact:

Tonya R. Moon, Ph.D.
Chair, Institutional Review Board for the Social and Behavioral Sciences
One Morton Dr Suite 500
University of Virginia, P.O. Box 800392
Charlottesville, VA 22908-0392
Email: irbsbshelp@virginia.edu
Website: https://research.virginia.edu/irb-sbs
Website for Research Participants: https://research.virginia.edu/research-participants

I am aware of the possibility of encountering interpretations of my IAT test performance with which I may not agree. Knowing this, I wish to proceed I am aware of the possibility of encountering interpretations of my IAT test performance with which I may not agree. Knowing this, I wish to proceed using a touchscreen OR using a keyboard.

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On the next page you'll be asked to select an Implicit Association Test (IAT) from a list of possible topics . We will also ask you (optionally) to report your attitudes or beliefs about these topics and provide some information about yourself.

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The OAC would like to thank the Rudd Center for Food Policy and Obesity for assistance in creating this brochure.

"The alarming rates of obesity have brought widespread attention to the medical consequences of this public health problem. Often ignored, however, are the social and personal obstacles that individuals with excess weight or obesity face. Bias, stigma, and discrimination due to weight are frequent experiences for many individuals with obesity, which have serious consequences for their personal and social well being and overall health. Given that at least half of the American population is overweight, the number of people potentially faced with discrimination and stigmatization is immense."
- Rebecca Puhl, PhD, Deputy Director at the Rudd Center for Food Policy and Obesity.
Weight stigma plays a role in everyday life, including work, school and healthcare settings. It remains a socially acceptable form of prejudice in American society, and is rarely challenged. One of the goals of the Obesity Action Coalition (OAC) is to eliminate the negative stigma associated with obesity. To do this, we must be able to define and recognize obesity stigma in all aspects of life. Once we are able to identify the nature and extent of this problem, we can increase education and awareness about the damaging and lasting effects of negative stigma.

Throughout this brochure, we will discuss the many forms of stigma and provide readers with options for dealing with stigma and ways to educate others.

Causes of Obesity:

Perceptions May Perpetuate Negative Stigma
Perceptions about the causes of obesity may contribute to weight stigma and bias. Assumptions that obesity can be prevented by self-control, that individual non-compliance explains failure at weight-loss, and that obesity is caused by emotional problems, are all examples of attitudes that contribute to negative bias.

Research suggests that beliefs about the causality and stability of obesity are also important factors contributing to negative attitudes. For example, studies show that individuals affected by obesity are more likely to be stigmatized if their overweight condition is perceived to be caused by controllable factors compared to uncontrollable factors (e.g., overeating versus a thyroid condition), and if obesity is perceived to be a condition of personal choice, versus a serious health condition.

Bias in Employment Settings

At Work
There is clear evidence of weight stigma and bias in multiple aspects of daily life for individuals affected by obesity. Negative perceptions of people affected by obesity exist in employment settings where employees affected by obesity are viewed as less competent, lazy and lacking in self discipline by their co-workers and employers. These attitudes can have a negative impact on wages, promotions and decisions about employment status for employees affected
by obesity.

Experimental studies also show that applicants affected by obesity are less likely to be hired than thinner applicants, despite having identical job qualifications. There are also increasing legal cases emerging where employees affected by obesity have been fired or suspended because of their weight, despite demonstrating good job performance and even though their body weight was unrelated to their job responsibilities.

Bias in employment settings has been identified in the following areas:

Hiring preferences

Promotions

Wage inequities

Employment termination

Hiring Preferences:
Job applicants affected by obesity are rated as having:

Poor self-discipline

Low supervisory potential

Poor personal hygiene

Less ambition & productivity

Higher likelihood of being hired for a job requiring little face-to-face contact

Promotions:
Applicants affected by obesity are rated as having:

Wage Inequities:
The following are true in regards to wage inequities for individuals affected by obesity:

Employment Termination:
Employees affected by obesity are affected more often in the following examples than employees not affected by obesity:

Bias in Education

In School
Multiple forms of weight stigmatization also occur in educational settings. Students affected by obesity face numerous obstacles, ranging from harassment and rejection from peers at school, to biased attitudes from teachers, lower college acceptances and wrongful dismissals from college.

The severity of this problem is highlighted by research showing that stigma toward students affected by obesity begins very early. For example, negative attitudes have been reported among pre-school children (ages three to five) who associated peers affected by obesity with characteristics of being mean, stupid, ugly and having few friends.

Bias in education is expressed through extensive peer victimization at school, and negative attitudes by teachers, administrators and academic institutions.
Weight Bias by Peers:

Negative attitudes begin as early as preschool.

Children affected by obesity are teased by kids and chosen less as playmates.

Stigmatization continues through high school and college, where students affected by obesity are viewed as

self-indulgent, lazy and are excluded from social activities.

Peer Victimization:

At least 30 percent of girls with excess weight and 24 percent of boys with excess weight report being teased by peers at school.

Adolescents at the heaviest weight are most likely to be teased because of their weight.

Overall, as many as 63 percent of girls and 58 percent of boys report peer victimization.

Having excess weight predicts future peer victimization.

Bias by Educators:

Teachers report that students affected by obesity are perceived as:

Untidy

More emotional

Less likely to succeed at school

More likely to have family problems

Educational Institutions:

Children with excess weight are less likely to be accepted to college, despite equivalent application rates and academic achievement.

Students affected by obesity are sometimes dismissed from college because of their weight.

Weight Bias in Healthcare

In Healthcare Settings
Unfortunately, weight stigma also exists in healthcare settings. Negative attitudes about individuals with excess weight have been reported by physicians, nurses, dietitians, psychologists and medical students. Research shows that even healthcare professionals who specialize in the treatment of obesity hold negative attitudes.

Bias may have a negative impact on quality of healthcare for individuals affected by obesity. Some studies have indicated that these individuals are reluctant to seek medical care, and may be more likely to delay important preventative healthcare services and cancel medical appointments. Weight bias has been reported as one reason for these negative experiences.
Research indicates that 46 percent of women affected by obesity reported that small gowns, narrow exam tables and inappropriately sized medical equipment were barriers to receiving healthcare. In addition, 35 percent reported embarrassment about being weighed as a barrier to care.
(source: Amy NK, Aalborg A, Lyons P, & Keranen L. Barriers to routine gynecological cancer screening for White and African-American women with obesity. Int J Obesity & Related Metabolic Disorders. 2006; 30: 147-155.)
Physicians:
Self-report studies show that physicians often view individuals affected by obesity as described below more often than they do individuals not affected by obesity :

Physicians are common sources of stigma. In a study that surveyed more than 2,400 adult women about their experiences of weight bias, 69 percent of respondents reported that physicians were a source of weight bias, and 52 percent reported they had been stigmatized by a doctor on multiple occasions.
Doctors were the second most frequent source of bias reported, out of a list of more than 20 possible sources of weight stigma.
(source: Puhl, R., & Brownell, K.D. (2006). Confronting and coping with weight stigma: An investigation of overweight and individuals with obesity. Obesity, 14, 1802-1815.)
Nurses:
Self-report studies show that nurses view individuals affected by obesity as non-compliant, overindulgent, lazy and unsuccessful. Studies of self-reported attitudes among nurses indicate that:

Psychologists:
In studies comparing beliefs about individuals affected by obesity versus "average" weight individuals, psychologists ascribe the following attributes to clients affected by obesity:

More pathology

More severe psychological symptoms

More negative attributes

Worse prognosis in treatment

Quality of Care:

Individuals affected by obesity are also more likely to have the following challenges with quality of care:

Fewer preventive health services and exams

Less access to cancer screening tests, such as pelvic exams and mammograms

More frequent cancellation or delay of appointments

Less time spent with the physician, less intervention and less discussion with the physician

Consequences of Weight Bias

Taken together, the consequences of being denied jobs, rejected by peers and treated inappropriately by healthcare professionals because of one's weight can have a serious and negative impact on quality of life. Individuals affected by obesity suffer terribly from this, both from direct discrimination and from more subtle forms of bias that are frequently encountered.

Weight bias can have psychological, social and physical health consequences on those affected by this disease.

Psychological outcomes can include:

The social effects can include:

The physical health outcomes can include:

What Can Be Done to Eradicate the Problem of Weight Bias?

Given how acceptable weight stigma is in our society, transforming societal attitudes and enacting laws that prohibit discrimination based on weight are needed in order to eliminate the problem of stigma toward individuals affected by obesity. Although this requires enormous efforts, there are other important steps that can be taken by both individuals and their healthcare providers to help improve the daily functioning and well-being of individuals affected by obesity.

Individuals as Advocates
Individuals who are struggling with weight stigma can begin to approach this problem by becoming advocates for themselves. This includes identifying situations in which they have been stigmatized because of their weight and deciding how best to handle the situation to achieve positive emotional health and to help prevent additional stigma from occurring. Specific strategies for dealing with weight stigma are highlighted below.

Individual Strategies to Deal with Weight Stigma:
It is important to note that there are many different strategies of coping with weight stigma and some strategies may be more or less effective with different types of stigmatizing situations.
An Important Role for Healthcare Professionals
Healthcare can easily become a negative and shaming experience for individuals affected by obesity because of weight stigma. Therefore, healthcare professionals have an extremely important role to play in addressing the problem of weight bias.

Encouraging individuals to share their experiences of stigma and to help them feel less isolated in these experiences is an important first step. Clinicians can also help individuals identify ways to effectively cope with stigma, such as using positive "self-talk," obtaining social support from others and participating in activities that they may have restricted due to feelings of shame about their weight.
These tools can help reduce the tendency of individuals affected by obesity to internalize negative stereotypes of obesity and blame themselves, both of which can negatively impact emotional well-being.
A second role for healthcare professionals is to address the issue of weight bias within themselves, their medical staff and colleagues. In order to be effective and empathic with individuals affected by obesity, this requires honest self-examination of one's own attitudes and weight bias. Education can help increase awareness among healthcare professionals about the pervasiveness and consequences of weight bias and can also encourage providers to adopt a more accurate and empathic understanding of their patients affected by obesity.

Finally, healthcare professionals can do a great service to their patients affected by obesity by improving the physical and social environment of healthcare settings. This means having bathrooms that are easily negotiated by heavier individuals, sturdy armless chairs in waiting rooms, offices with large exam tables, gowns and blood pressure cuffs in appropriate sizes and reading materials for individuals that are appropriate and "weight-friendly" (rather than fashion magazines with thin supermodels). The following checklist provides suggested guidelines to improve the healthcare environment for individuals affected by obesity:
Exam Room Waiting Room Scale

Wide-based scale that measures greater than 350 pounds

Meets established accuracy requirements

Accessible for individuals with disabilities

Situated in a physical location that offers privacy and confidentiality

Wide platform with handles for support during weighing

Healthcare professionals can also improve their interpersonal interactions by being sensitive to situations of embarrassment for individuals, such as weighing individuals in a private and sensitive manner, without judgmental commentary. Asking individuals for their permission to be weighed at each visit is an easy and sensitive way to begin the weighing procedure. Providers can also help by emphasizing goals of health and fitness behaviors (rather than only the number on the scale) and celebrating positive health behavior changes made by individuals.

To download a PDF of this brochure, click here.

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Understanding Obesity Stigma Brochure - Obesity Action Coalition

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The OAC would like to thank the Rudd Center for Food Policy and Obesity for assistance in creating this brochure. "The alarming rates of obesity have brought widespread attention to the medical consequences of this public health problem.

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1.      “A bariatric surgery story “

2.      “Millions of Americans qualify for bariatric surgery. Do you?”

3.      “Learn the facts about bariatric surgery”

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American Society for Metabolic and Bariatric Surgery

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Obesity is no longer considered a cosmetic issue that is caused by overeating and a lack of self-control. The World Health Organization (W.H.O.), along with National and International medical and scientific societies, now recognize obesity as a chronic progressive disease resulting from multiple environmental and genetic factors.

The disease of obesity is extremely costly not only in terms of economics, but also in terms of individual and societal health, longevity, and psychological well-being. Due to its...

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Treat your Obesity | Patient Learning Center | ASMBS

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Obesity is no longer considered a cosmetic issue that is caused by overeating and a lack of self-control. The World Health Organization (W.H.O.), along with National and International medical and scientific societies, now recognize obesity as a chronic progressive disease resulting from multiple environmental and genetic factors.

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How to use the tool, guidelines for all phases, label reading, preparing for nutrition changes

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Reviews peri- and post-operative nutrition timeline, and protein needs

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Parrott J, Frank L, Rabena R, Craggs-Dino L, Isom KA, Greiman L. American Society for Metabolic and Bariatric Surgery Integrated Health Nutritional Guidelines for the Surgical Weight Loss Patient 2016 Update: Micronutrients. Surg Obes Relat Dis. 2017 May;13(5):727-741. doi: 10.1016/j.soard.2016.12.018. Epub 2017 Jan 19. PMID: 28392254.

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PowerPoint from CBL module

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Blackwood 2012, RN Post-op care for the bariatric surgery patient
PowerPoint slides to prepare nurses for dealing with the challenges that the bariatric patient may present with during their acute and subsequent hospital admissions.
This course will provide a foundation for the understanding of postoperative gastrointestinal anatomy, assist nurses in assessment and care of the obese patient, and enhance knowledge base for prompt recognition of early and long term postoperative complications associated with the treatment of bariatric surgical patients.

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Clinical Pearls for Emergency Care of the Bariatric Surgery Patient

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Clinical Pearls for Emergency Care of the Bariatric Surgery Patient

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ASMBS (2010)

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BEAM-ED (Bariatric Examination, Assessment, and Management in the Emergency Department) is a web based clinical tool developed as a collaborative project by the ASMBS and the American College of Emergency Physicians (ACEP) in effort to fulfill an ACEP objective to compile clinical resources for the care of bariatric patients in the emergency department. Members of ACEP and the ASMBS Clinical Issues Committee (CIC) developed the tool to educate ER physicians and provide clinical guidance on the assessment and management of common types of complications seen after current bariatric procedures. Although developed primarily for use by ER physicians, it is also a useful tool that can be shared with members of the bariatric surgery allied health team. The tool is a living document that will undergo routine periodic evaluations by the ASMBS CIC with revisions as determined necessary. https://asmbs.org/resources/beam-ed
https://www.acep.org/beam/

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BARIATRIC EXAMINATION, ASSESSMENT, and MANAGEMENT in the Emergency Department. Bedside tool for the patient with potential complications after bariatric surgery.

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Eisenberg D, Noria S, Grover B, Goodpaster K, Rogers AM; American Society for Metabolic and Bariatric Surgery Clinical Issues Committee. ASMBS position statement on weight bias and stigma. Surg Obes Relat Dis. 2019 Jun;15(6):814-821. doi: 10.1016/j.soard.2019.04.031. Epub 2019 May 10. PMID: 31196777.

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Early major complications after bariatric surgery 

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Early major complications after bariatric surgery 

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Chang SH, Freeman NLB, Lee JA, Stoll CRT, Calhoun AJ, Eagon JC, Colditz GA. Early major complications after bariatric surgery in the USA, 2003-2014: a systematic review and meta-analysis. Obes Rev. 2018 Apr;19(4):529-537. doi: 10.1111/obr.12647. Epub 2017 Dec 20. PMID: 29266740; PMCID: PMC5880318.

# data[].attributes.attachment_link.readable_text
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. 2018 Apr;19(4):529-537.

doi: 10.1111/obr.12647.

Affiliations

¹ Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA.

² Center for Advanced Methods Development, RTI International, NC, USA.

³ Agricultural Statistics Laboratory, University of Arkansas, Fayetteville, AR, USA.

⁴ Saint Louis University School of Medicine, St. Louis, MO, USA.

⁵ Minimally Invasive and Bariatric Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA.

Free PMC article

S-H Chang et al. Obes Rev.

Free PMC article

. 2018 Apr;19(4):529-537.

doi: 10.1111/obr.12647.

Affiliations

¹ Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA.

² Center for Advanced Methods Development, RTI International, NC, USA.

³ Agricultural Statistics Laboratory, University of Arkansas, Fayetteville, AR, USA.

⁴ Saint Louis University School of Medicine, St. Louis, MO, USA.

⁵ Minimally Invasive and Bariatric Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA.

Abstract

The effectiveness of bariatric surgery has been well-studied. However, complications after bariatric surgery have been understudied. This review assesses <30-d major complications associated with bariatric procedures, including anastomotic leak, myocardial infarction and pulmonary embolism. This review included 71 studies conducted in the USA between 2003 and 2014 and 107,874 patients undergoing either gastric bypass, adjustable gastric banding or sleeve gastrectomy, with mean age of 44 years and pre-surgery body mass index of 46.5 kg m⁻² . Less than 30-d anastomotic leak rate was 1.15%; myocardial infarction rate was 0.37%; pulmonary embolism rate was 1.17%. Among all patients, mortality rate following anastomotic leak, myocardial infarction and pulmonary embolism was 0.12%, 0.37% and 0.18%, respectively. Among surgical procedures, <30-d after surgery, sleeve gastrectomy (1.21% [95% confidence interval, 0.23-2.19%]) had higher anastomotic leak rate than gastric bypass (1.14% [95% confidence interval, 0.84-1.43%]); gastric bypass had higher rates of myocardial infarction and pulmonary embolism than adjustable gastric banding or sleeve gastrectomy. During the review, we found that the quality of complication reporting is lower than the reporting of other outcomes. In summary, <30-d rates of the three major complications after either one of the procedures range from 0% to 1.55%. Mortality following these complications ranges from 0% to 0.64%. Future studies reporting complications after bariatric surgery should improve their reporting quality.

Keywords: Anastomotic leak; bariatric surgery; myocardial infarction; pulmonary embolism.

Conflict of interest statement

Conflict of interests None.

Figures

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national center for biotechnology information

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Early major complications after bariatric surgery in the USA, 2003-2014: a systematic review and meta-analysis - PubMed

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The .gov means it's official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site. The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

# data[].attributes.headline
Carter 2021. ASMBS position statement on preoperative patient optimization before metabolic and bariatric surgery

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Carter 2021. ASMBS position statement on preoperative patient optimization before metabolic and bariatric surgery

# data[].attributes.headline
ASMBS: Care pathway for laparoscopic sleeve gastrectomy

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ASMBS: Care pathway for laparoscopic sleeve gastrectomy

# data[].attributes.body
Telem et al, 2017. ASMBS: Care pathway for laparoscopic sleeve gastrectomy

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ASMBS: Preoperative Care Pathway for Laparoscopic Roux-en-Y Gastric Bypass

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ASMBS: Preoperative Care Pathway for Laparoscopic Roux-en-Y Gastric Bypass

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Kindel et al, 2021. American Society for Metabolic and Bariatric Surgery (ASMBS): Preoperative Care Pathway for Laparoscopic Roux-en-Y Gastric Bypass

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Dumping syndrome after esophageal, gastric or bariatric surgery: pathophysiology, diagnosis, and management

# data[].attributes.subject
Dumping syndrome after esophageal, gastric or bariatric surgery: pathophysiology, diagnosis, and management

# data[].attributes.body
van Beek AP, Emous M, Laville M, Tack J. Dumping syndrome after esophageal, gastric or bariatric surgery: pathophysiology, diagnosis, and management. Obes Rev. 2017 Jan;18(1):68-85. doi: 10.1111/obr.12467. Epub 2016 Oct 17. PMID: 27749997.

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Affiliations

¹ Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.

² Department of Bariatric and Metabolic Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands.

³ European Center for Nutrition and Health (CENS), University of Lyon, 1 Civil Hospices of Lyon, Lyon, France.

⁴ Department of Gastroenterology, University Hospital Gasthuisberg, Leuven, Belgium.

Affiliations

¹ Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.

² Department of Bariatric and Metabolic Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands.

³ European Center for Nutrition and Health (CENS), University of Lyon, 1 Civil Hospices of Lyon, Lyon, France.

⁴ Department of Gastroenterology, University Hospital Gasthuisberg, Leuven, Belgium.

Abstract

Background: Dumping syndrome, a common complication of esophageal, gastric or bariatric surgery, includes early and late dumping symptoms. Early dumping occurs within 1 h after eating, when rapid emptying of food into the small intestine triggers rapid fluid shifts into the intestinal lumen and release of gastrointestinal hormones, resulting in gastrointestinal and vasomotor symptoms. Late dumping occurs 1-3 h after carbohydrate ingestion, caused by an incretin-driven hyperinsulinemic response resulting in hypoglycemia. Clinical recommendations are needed for the diagnosis and management of dumping syndrome.

Methods: A systematic literature review was performed through February 2016. Evidence-based medicine was used to develop diagnostic and management strategies for dumping syndrome.

Results: Dumping syndrome should be suspected based on concurrent presentation of multiple suggestive symptoms after upper abdominal surgery. Suspected dumping syndrome can be confirmed using symptom-based questionnaires, glycemia measurements and oral glucose tolerance tests. First-line management of dumping syndrome involves dietary modification, as well as acarbose treatment for persistent hypoglycemia. If these approaches are unsuccessful, somatostatin analogues should be considered in patients with dumping syndrome and impaired quality of life. Surgical re-intervention or continuous enteral feeding may be necessary for treatment-refractory dumping syndrome, but outcomes are variable.

Conclusions: Implementation of these diagnostic and treatment recommendations may improve dumping syndrome management.

Keywords: dumping syndrome; hyperinsulinemic hypoglycemia; pasireotide; somatostatin analogue.

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national center for biotechnology information

# data[].attributes.attachment_link.title
Dumping syndrome after esophageal, gastric or bariatric surgery: pathophysiology, diagnosis, and management - PubMed

# data[].attributes.attachment_link.description
1 Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands. 2 Department of Bariatric and Metabolic Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands. 3 European Center for Nutrition and Health (CENS), University of Lyon, 1 Civil Hospices of Lyon, Lyon, France. 4 Department of Gastroenterology, University Hospital Gasthuisberg, Leuven, Belgium.

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Medical weight bias causes misdiagnosis of pain, and depression

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'It wasn't about my weight': How weight stigma keeps women from treatment

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Weight stigma in health care prevents women from receiving proper care while causing them stress, depression, anxiety and causing maladaptive behaviors.

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Medical management of patients after bariatric surgery: Principles and guidelines.

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Medical management of patients after bariatric surgery: Principles and guidelines.

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Elrazek AE, Elbanna AE, Bilasy SE. Medical management of patients after bariatric surgery: Principles and guidelines. World J Gastrointest Surg. 2014 Nov 27;6(11):220-8. doi: 10.4240/wjgs.v6.i11.220. PMID: 25429323; PMCID: PMC4241489.

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Abstract

Obesity is a major and growing health care concern. Large epidemiologic studies that evaluated the relationship between obesity and mortality, observed that a higher body-mass index (BMI) is associated with increased rate of death from several causes, among them cardiovascular disease; which is particularly true for those with morbid obesity. Being overweight was also associated with decreased survival in several studies. Unfortunately, obese subjects are often exposed to public disapproval because of their fatness which significantly affects their psychosocial behavior. All obese patients (BMI ≥ 30 kg/m ²) should receive counseling on diet, lifestyle, exercise and goals for weight management. Individuals with BMI ≥ 40 kg/m ² and those with BMI > 35 kg/m ² with obesity-related comorbidities; who failed diet, exercise, and drug therapy, should be considered for bariatric surgery. In current review article, we will shed light on important medical principles that each surgeon/gastroenterologist needs to know about bariatric surgical procedure, with special concern to the early post operative period. Additionally, we will explain the common complications that usually follow bariatric surgery and elucidate medical guidelines in their management. For the first 24 h after the bariatric surgery, the postoperative priorities include pain management, leakage, nausea and vomiting, intravenous fluid management, pulmonary hygiene, and ambulation. Patients maintain a low calorie liquid diet for the first few postoperative days that is gradually changed to soft solid food diet within two or three weeks following the bariatric surgery. Later, patients should be monitored for postoperative complications. Hypertension, diabetes, dumping syndrome, gastrointestinal and psychosomatic disorders are among the most important medical conditions discussed in this review.

Keywords: Obesity, Bariatric surgery, Postoperative care, Body-mass index, El banna

Core tip: Obesity is a growing health concern worldwide that impacts the life of individuals both physically and psychologically. There are several well-established health hazards associated with obesity. Additionally, obese subjects are often exposed to public disapproval because of their fatness which significantly affects their psychosocial behavior. Bariatric surgery is one of the definite solutions for obesity. In this review, we will briefly discuss the general guidelines that should be considered before bariatric surgery. Also, we discuss the protocols of patients' postoperative care and the management of medical disorders that must be considered after bariatric surgery.

INTRODUCTION

Obesity is a chronic disease that impairs health-related quality of life in adolescents and children. In 2010, overweight and obesity were estimated to cause 3.4 million deaths, 3.9% of years of life loss, and 3.8% of disability-adjusted life-years worldwide. Obesity is increasing in prevalence, currently, the proportion of adults with a body-mass index (BMI) of 25 kg/m ² or greater is 36.9% in men and 38.0% in women worldwide[ 1]. Attempts to explain the large increase in obesity in the past 30 years focused on several potential contributors including increase in caloric intake, changes in the composition of diet, decrease in the levels of physical activity and changes in the gut microbiome. More than 50% of the obese individuals in the world are located in ten countries (listed in order of number of obese individuals): United States, China, India, Russia, Brazil, Mexico, Egypt, Germany, Pakistan and Indonesia. Although age-standardized rates were lower in developing than in developed countries overall, 62% of the world's obese individuals live in developing countries. Recently, United States accounted for 13% of obese people worldwide, the prevalence of obesity was 31.7% and 33.9% among adult men and women, respectively. In Canada 21.9% of men and 20.5% of women are obese. Reported prevalence rates of obesity include: 27.5% of men and 29.8% of women in Australia, 24.5% of men and 25.4% of women in the United Kingdom, in Germany 21.9% of men and 22.5% of women, in Mexico 20.6% of men and 32.7% of women, in South Africa 13.5% of men and 42% of women, in Egypt 26.4% of men and 48.4% of women, in Saudi Arabia 30% of men and 44.4% of women and in Kuwait 43.4% of men and 58.6% of women (Table , Figure )[ 2]. There are several well-established health hazards associated with obesity, e.g., nonalcoholic steatohepatitis (NASH), type 2 diabetes, heart disease, chronic kidney disease, gastroesophageal reflux disease, gastrointestinal motility disorders, sexual disorders, cerebrovascular stroke, certain cancers, osteoarthritis, depression and others[ 3- 10]. The risk of development of such complications rises with the increase of adiposity, while weight loss can reduce the risk. Bariatric surgery could be the definitive clue in many situations[ 11- 15]. Bariatric surgery is one of the fastest growing operative procedures performed worldwide, with an estimated > 340000 operations performed in 2011. While the absolute growth rate of bariatric surgery in Asia was 44.9% between 2005 and 2009, the numbers of procedures performed in the United States plateaued at approximately 200000 operations per year[ 16, 17]. Starting in 2006, the Center for Medicare and Medicaid Services, United States, restricted the coverage of bariatric surgery to hospitals designated as "Centers of Excellence" by two major professional organizations[ 18]. Medical management and follow up of patients who have undergone bariatric surgery is a challenge due to post operative complications.

GENERAL GUIDELINES FOR SURGEONS/GASTROENTEROLOGISTS

A well skilled physician or a surgeon has to consider the followings: (1) as the prevalence of obesity increases so does the prevalence of the comorbidities associated with obesity. Losing weight means overcoming illness at the present, complications in future and alleviating the economic burden in the present and future; (2) Overweight; BMI between 25 and 30, technically refers to excessive body weight, whereas "obesity " BMI ≥ 30 kg/m ² refers excessive body fat, "Severe obesity", BMI ≥ 35 kg/m ², or "morbid obesity" refers to individuals with obesity-related comorbidities. Furthermore, severe obesity and morbid obesity groups who failed dietary and medical regimens are candidates for bariatric surgery; (3) Children obesity; refers to children with BMI > 95 th percentile for their age and sex and "overweight" refers to children with BMI between the 85 th and 95 th percentile for their age and sex; (4) Patients undergoing a bariatric operation should have a nutritional assessment for deficiencies in macro and micronutrients, also with no contraindication for such a major operation; (5) Most of bariatric procedures are performed in women (> 80%) and approximately half of these (> 40% of all bariatric procedures) are performed in reproductive aged women, accordingly, pregnancy planning and contraception options should be discussed in details with women who will undergo bariatric procedures. Fertility improves soon after bariatric surgery, particularly in middle-aged women, who were anovulatory. Additionally, oral contraceptives may be less effective in women who have undergone malabsorptive bariatric procedure. Therefore, it is better to delay pregnancy for 6-12 mo following bariatric surgery. Risk of preeclampsia, gestational diabetes, and macrosomia significantly decrease post bariatric surgery, but the risk of intrauterine growth restriction/small infants for their gestational age may increase. Body contouring surgery is in high demand following bariatric surgery; (6) All bariatric operations are accompanied with restrictive and/or malabsorption maneuvers; less food intake and malabsorption concepts; (7) The most common types of bariatric surgeries performed worldwide are Sleeve gastrectomy (SG): This procedure involves the longitudinal excision of the stomach and thus shaping the remaining part of the stomach into a tube or a "sleeve" like structure. SG removes almost 85% of the stomach (Figure ); Roux-en-Y gastric bypass (RYGB): It reduces the size of the stomach to the size of a small pouch that is directly surgically attached to the lower part of the small intestine. In this procedure, most of the stomach and the duodenum are surgically stapled and therefore, bypassed (Figure ); The laparoscopic adjustable gastric band (AGB): This is one of the least invasive procedures, where the surgeon inserts an adjustable band around a portion of the stomach and therefore, patients feel fuller after eating smaller food portions (Figure ). Bariatric surgical procedures, particularly RYGB, plus medical therapy, are effective interventions for treating type 2 diabetes. Improvement in metabolic control is often evident within days to weeks following RYGB; and (8) Complications reported following bariatric surgery vary based upon the procedure performed. Cholilithiasis, renal stone formation and incisional hernia could be the delayed phase complications; on the other hand, bleeding, leaking, infection and pulmonary embolism could be the early phase complications following the bariatric procedure. The overall 30-d mortality for bariatric surgical procedures worldwide is less than 1%.

POST OPERATIVE CARE AND FOLLOW UP

Early post operative period; (1-3) d post bariatric surgery

Patients undergoing a bariatric operation are admitted to the post-anesthesia care unit (PACU) immediately at the conclusion of the operation. Usually, on postoperative day (POD) one, we begin oral therapy in tablet or crushed-tablet and liquid form if there is a naso-gastric tube after the gastrografin leak test. A basic metabolic profile ( e.g., complete blood count, electrolytes, renal function, liver function, prothrombin time and partial thromboplastin time) should be obtained every 12 h for the successive two PODs, then every 24 h for another 3 d. Oxygen is administered by nasal cannula and weaned thereafter. The likelihood that, early specific complication, will arise for a given patient is determined by the nature of the procedure, the anesthetic techniques used, and the patient's preoperative diseases. Respiratory problems are common complication in the early postoperative period following bariatric surgery. Patients with significant comorbidities, particularly neuromuscular, pulmonary, or cardiac problems are at a higher risk for respiratory compromise, but any patient can develop hypoxemia following bariatric surgery. For prophylaxis against Deep Venous Thrombosis (DVT) following bariatric surgeries, ultrasound evaluation is recommended for all patients, D-dimer test should be applied for suspected patients with DVT, especially after long operative time, repeat ultrasound or venography may be required for those with suspected calf vein DVT and a negative initial ultrasound investigation[ 19, 20].

Late post operative monitoring

After the PACU period, most patients are transferred to the inpatient surgical postoperative unit. For the next 24-72 h, the postoperative priorities include ruling out an anastomotic leak following laparoscopic RYGB or laparoscopic SG. If no leak is observed, patients are allowed to start a clear liquid diet and soft drinks. The postoperative care team cares for the following: control of pain, care of the wound, continuous monitoring of blood pressure, intravenous fluid management, pulmonary hygiene, and ambulation. Post-bariatric nausea and vomiting is directly correlated with the length of the surgery; it also increases in females, non-smokers, and those patients with prior history of vomiting or motion sickness. Prophylaxis with pharmacologic treatment before the development of post operative nausea and vomiting significantly reduces its incidence after surgery[ 21- 23].

After hospital discharge

Diet: Usually patients are discharged 4-6 d after surgery. Most patients are typically discharged from the hospital on a full liquid diet, patients should be taught to keep monitoring their hydration and urine output. Approximately two-three weeks after surgery, the diet is gradually changed to soft, solid foods. The average caloric intake ranges from (400) to (800) kcal/d for the first month, and thus the daily glycemic load is greatly reduced. We encourage patients to consume a diet consisting of salads, fruits, vegetables and soft protein daily.

To control the epigastric pain and vomiting, patients should be taught to eat slowly, to stop eating as soon as they reach satiety and not to consume food and beverages at the same time. For most patients suffering chronic vomiting, prokinetic therapy and proton-pump inhibitors (PPIs) should be considered. Patients, who underwent SG, LAGB or RYGB, benefit from a well-planned dietary advancement. Patients should understand that the surgery has changed their body but not the environment, they have to choose healthy foods, do not skip meals and to visit the dietitian regularly in the first 12 mo after surgery. However, if food intolerance develops, patients may choose a more vegetarian-based diet. Nevertheless, fresh fruits and vegetables are usually tolerated without a problem. The daily protein intake should be between 1.0 to 1.5 g/kg ideal body weight per day[ 24]. The biliopancreatic diversion/duodenal switch (BPD/DS) is a malabsorptive procedure for both macro- and micronutrients. Hence, we encourage higher protein intake of 1.5 g to 2.0 g of protein/kg ideal body weight per day, making the average protein requirement per day approximately 90 g/d[ 25, 26]. Alcohol is better prevented in the first 6-12 mo after surgery[ 27].

Monitoring: Patients should generally have their weight and blood pressure measured weekly until the rapid weight loss phase diminishes, usually within 4-6 mo, then again at 8, 10 and 12 mo, and annually thereafter. Patients with diabetes are encouraged to check their blood glucose daily. Glycemic control typically improves rapidly following bariatric surgery. Patients maintained on antihypertensive or diabetic medications at discharge should be monitored closely for hypotension and hypoglycemia, respectively, and medications should be adjusted accordingly. We recommend that the following laboratory tests be performed at three, six, nine months and annually thereafter: (1) Complete Blood Count; (2) Electrolytes; (3) Glucose and Glucose Tolerance test; (4) Complete iron studies; (5) Vitamin B12; (6) Aminotransferases, alkaline phosphatase, bilirubin, GGT; (7) Total protein and Albumin; (8) Complete lipid profile; (9) 25-hydroxyvitamin D, parathyroid hormone; (10)Thiamine; (11) Folate; (12) Zinc; and (13) Copper.

Complications following the surgical treatment of severe obesity vary based upon the procedure performed. Secondary hyperparathyroidism, Hypocalcemia, Gastric remnant distension, Stomal stenosis/Obstruction, Marginal ulcerations, Cholilithiasis, Ventral incisional hernia, Internal hernia, Hiatus Hernia, Short bowel syndrome, Renal failure, Gastric prolapse, infection, Esophagitis, Reflux, Vomiting, Hepatic abnormalities and dumping syndrome are common late-phase complications after bariatric surgery. However, the clinician should aware of complications specific for every bariatric procedure[ 28, 29]. Before therapy, the clinician should understand that the impact of various bariatric surgeries on drug absorption and metabolism are scarce. On the other hand, RYGB and other malabsorptive procedures that significantly exclude the proximal part of the small intestine, decrease the surface area where most drug absorption occurs and may result in a reduction in systemic bioavailability[ 30- 32].

COMMON MEDICAL CONDITIONS FOLLOWING BARIATRIC SURGERY

Hypertension

Hypertension is not always related to obesity, and dietary interventions do not assure the normalization of blood pressure. However weight loss, whether by an intensive lifestyle medical modification program or by a bariatric operation, improves obesity-linked hypertension. Patients should be monitored weekly until the blood pressure has stabilized, and patients may need to resume antihypertensive medications, but often at adjusted doses[ 33].

Diabetes

Patients with diabetes should have frequent monitoring of blood glucose in the early postoperative period and should be managed with sliding scale insulin. Many diabetic patients have a decreased need for insulin and oral hypoglycemic agents after bariatric surgery. Oral sulfonylureas and meglitinides should be discontinued postoperatively as these medications can lead to hypoglycemia after bariatric surgery. Metformin is the safest oral drug in the postoperative period, since it is not associated with dramatic fluctuations in blood glucose. RYGB is associated with durable remission of type 2 diabetes in many, but not all, severely obese diabetic adults. However those who underwent LAGB generally exhibit a slower improvement in glucose metabolism and diabetes as they lose weight in a gradual fashion[ 34, 35].

Reflux

Medications for gastroesophageal reflux disease (GERD) may be discontinued after RYGB and Laparoscopic AGB, however, SG has been associated with an increased incidence of GERD in some procedures. Recurrent GERD symptoms after RYGB, particularly when accompanied by weight regain, should raise the possibility of a gastrogastric fistula between the gastric pouch and remnant, and should be investigated by an upper GI contrast study or CT scan and referred to the bariatric surgeon. Upper endoscopy is the best investigation to exclude other esophagogastroduodenal disorders. GERD may be associated with esophageal complications including esophagitis, peptic stricture, Barrett's metaplasia, esophageal cancer and other pulmonary complications. Failure of the PPI treatment to resolve GERD-related symptoms has become one of the most common complications of GERD after bariatric surgery. Most patients who fail PPI treatment have Non Erosive Reflux Disease and without pathological reflux on pH testing. In patients with persistent heartburn despite of medical therapy, it is reasonable to recommend avoidance of specific lifestyle activities that have been identified by patients or physicians to trigger GERD-related symptoms[ 36- 38].

Nausea and vomiting

Nausea and vomiting can often be helped by antiemetic or prokinetic drugs, however, some patients have chronic functional nausea and/or vomiting that does not fit the pattern of cyclic vomiting syndrome or other gastrointestinal disorders, hence particular attention should be directed to potential psychosocial factors post bariatric surgery. Therefore, low dose antidepressant medications and psychotherapy should be addressed. On demand CT scan and Gastroscopy could be the gold standard investigations in chronic situations[ 39, 40].

Marginal ulceration

Due to increased risk of ulcer formation from nonsteroidal anti-inflammatory drugs (NSAIDs), these medications should be discontinued postoperatively, especially after RYGB. NSAID use is associated with an increased risk of bleeding. If analgesic or anti-inflammatory treatment is needed, the use of acetaminophen is preferred in a dose of 1-2 g/daily[ 41- 45]. Other factors associated with increased risk of ulcer formation are smoking, alcohol, spicy food, gastrogastric fistulas, ischemia at the site of surgical anastomosis, poor tissue perfusion due to tension, presence of foreign material, such as staples and/or Helicobacter pylori infection. Diagnosis is established by upper endoscopy. According to our strategy, all patients should undergo diagnostic upper endoscopy to exclude congenital or GI diseases prior to bariatric procedures. Medical management is usually successful and surgical intervention is rarely needed[ 46- 48].

DUMPING SYNDROME

Dumping syndrome or rapid gastric emptying is a group of symptoms that most likely occur following bariatric bypass. It occurs when the undigested contents of the stomach move too rapidly into the small intestine. Many patients who underwent bariatric bypass experienced postprandial hypoglycemia. However, the dumping syndrome usually occurs early (within one hour) after eating and is not associated with hypoglycemia. It is presumed to be caused by contraction of the plasma volume due to fluid shifts into the gastrointestinal tract. Dumping syndrome may result in tachycardia, abdominal pain, diaphoresis, nausea, vomiting, diarrhea, and sometimes, hypoglycemia. The late dumping syndrome is a result of the hyperglycemia and the subsequent insulin response leading to hypoglycemia that occurs around 2-3 h after a meal. Dumping syndrome is a common problem that occurs in patients who have undergone RYGB and when high levels of simple carbohydrates are ingested. Accordingly, patients who have experienced postgastric bypass bariatric surgery should avoid foods that are high in simple sugar content and replace them with a diet consisting of high fiber and protein rich food. Eating vegetables and salad is encouraged; beverages and alcohol consumption are better avoided[ 49].

PSYCHOSOMATIC DISORDERS/DEPRESSION

Many patients usually experience enhanced self esteem and improved situational depression following weight loss. Depression often requires continued treatment, specially that, many patients with severe obesity often use food for emotional reasons. Therefore, when those patients experience a small gastric pouch postoperatively they may grieve the loss of food. Many studies documented the relationship between eating disorder and anxiety disorder, depression or schizophrenia[ 50, 51]. Displaced emotions can result in somatization with symptoms of depression and psychosomatic disorders. It is important that clinicians recognize the psychological aspect of food loss after bariatric surgery, and reassure patients that the symptoms are related to the small gastric pouch size. Antidepressants often help to decrease the anxiety related to grieving associated with food loss, although the use of antidepressants needs to be approached with an empathetic style. Behavioral and emotive therapies are reported to be very helpful[ 52, 53].

OUTCOME

Bariatric surgery remains the only effective sustained weight loss option for morbidly obese patients. The American Society for Metabolic and Bariatric Surgery estimated that in 2008 alone, about 220000 patients in the United States underwent a weight loss operation. The optimal choice for type of bariatric procedure, i.e., RYGB, SG, AGB or the selected surgical approach, i.e., open versus laparoscopic depends upon each individualized goals, i.e., weight loss, glycemic control, surgical skills, center experience, patient preferences, personalized risk assessment and other medical facilities. Laparoscopic sleeve gastrectomy is the most common bariatric procedure. However weight re-gain after long-term follow-up was reported[ 54- 58]. Prospective studies and reviews report a general tendency for patients with metabolic disorders to improve or normalize after bariatric surgery. However weight loss is highly variable following each procedure. Recent studies have evaluated the potential impact of obesity on outcomes in organ-transplant recipients, for example bariatric surgery may be an important bridge to transplantation for morbidly obese patients with severe heart failure[ 59- 63].

RECENT ADVANCES IN BARIATRIC SURGERY

A modified intestinal bypass bariatric procedure (Elbanna operation), reported a novel surgical technique designed to maintain good digestion, better satiety, and selective absorption with less medical and surgical complications (Figure ). This procedure preserves the proximal duodenum and the terminal ileum and thus preserving the anatomical biliary drainage and enterohepatic circulation[ 64, 65].

Recently, a novel bariatric technique dedicated; Modified Elbanna technique in childhood bariatric, showed promising success in pediatric surgeries (non published data).

CONCLUSION

The rising prevalence of overweight and obesity in several countries has been described as a global pandemic. Obesity can be considered like the driving force towards the pre-mature deaths. It increases the like hood for the development of diabetes, hypertension and NASH. The American Heart Association identified obesity as an independent risk factor for the development of coronary heart disease. In order to minimize post-surgical cardiovascular risk, surgical weight loss may become a more frequently utilized option to address obesity. Currently, bariatric surgery passes through a plateau phase, hence medical management and follow up of patients who have undergone bariatric surgery is a challenge.

FUTURE RECOMMENDATIONS

Children obesity has become one of the most important public health problems in many industrial countries. In the United States alone, 5% of children have severe obesity. It is imperative that health care providers should identify overweight and obese children so as to start early counseling and therapy. To establish a therapeutic relationship and enhance effectiveness, the communication and interventions should be supported by the entire family, society, school, public media and primary health care. Bariatric surgery could be considered in complicated cases that failed all other options.

Footnotes

P- Reviewer: Amiya E, Firstenberg MS, Narciso-Schiavon JL S- Editor: Tian YL L- Editor: A E- Editor: Lu YJ

References

7. UN Department of Economic and Social Affairs, Population Division. World population prospects: the 2010 revision. Volume 1: Comprehensive tables. New York: United Nations; 2011. [ Google Scholar]

64. Elbanna A, Tawella N, Neff K, Abd Elfattah A, Bakr I. Abstracts from the 18th World Congress of the International Federation for the Surgery of Obesity & Metabolic Disorders (IFSO), Istanbul, Turkey 28-31 August 2013. Obes Surg. 2013;23:1017-1243. [ Google Scholar]

65. Elbanna A, Taweela NH, Gaber MB, Tag El-Din MM, Labib MF, Emam MA, Khalil OO, Abdel Meguid MM, Abd Elrazek MAA. Medical Management of Patients with Modified Intestinal Bypass: A New Promising Procedure for Morbid Obesity. GJMR. 2014;14:8-19. [ Google Scholar]

Articles from World Journal of Gastrointestinal Surgery are provided here courtesy of Baishideng Publishing Group Inc

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Medical management of patients after bariatric surgery: Principles and guidelines

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Obesity is a major and growing health care concern. Large epidemiologic studies that evaluated the relationship between obesity and mortality, observed that a higher body-mass index (BMI) is associated with increased rate of death from several causes, among them cardiovascular disease; which is particularly true for those with morbid obesity.

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Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support

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Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support

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Mechanick et al. 2020 Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures –2019 update: cosponsored by AACE/ ACE, TOS , ASMBS, OMA, ASA

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The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) has launched a new surgical risk/benefit calculator that will provide metabolic and bariatric surgeons and their patients with accurate, patient-specific information to guide surgical decision making and informed consent.

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The Individualized Diabetes Complications (IDC) Risk Scores provide personalized evidence-based risk information for patients with type 2 diabetes and obesity about their future risk of cardiovascular outcomes and death, based on current status of obesity, diabetes, and related health conditions, with and without bariatric and metabolic surgery.

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American Society for Metabolic and Bariatric Surgery

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Default numbers were used to calculate these results.

You should return to this calculator once you have your real numbers from your regular doctor, so that your results are as accurate as possible.

Your 10-year risk of death (all-cause) would be lower after surgery for diabetes.

Your 10-year risk of heart failure would be lower after surgery for diabetes.

Your 10-year risk of coronary heart disease would be lower after surgery for diabetes.

Your 10-year risk of diabetic kidney disease would be lower after surgery for diabetes.

Your 10-year risk of cerebrovascular disease (stroke)* would be lower after surgery for diabetes.

10 Year Outcomes for 100 People like you

References

[1] Aminian A, Zajichek A, Arterburn DE, Wolski KE, Brethauer SA, Schauer PR, Kattan MW, Nissen SE. Association of Metabolic Surgery With Major Adverse Cardiovascular Outcomes in Patients With Type 2 Diabetes and Obesity. JAMA. 2019;322:1271-1282

[2] Aminian A, Zajichek A, Arterburn DE, Wolski KE, Brethauer SA, Schauer PR, Nissen SE, Kattan MW. Individualized Diabetes Complications Risk Scores: Future Risk of Diabetes End-Organ Complications with and without Metabolic Surgery.

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Diabetes Surgery Risk Calculator | Escape Diabetes

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Calculate your future risk of diabetes-related health conditions with and without surgical intervention.

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‎A tool for bariatric surgeons to help assess a patient’s risk and to choose the best procedure for the patient.

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Bariatric Surgery calculator- Android app

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Bariatric Surgery calculator- Android app

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Bariatric Surgery Calculator - Apps on Google Play

# data[].attributes.attachment_link.description
A tool for bariatric surgeons to help assess a patient’s risk