Transcript Workshop 3 Long-term care of post bariatric surgery

Slide set for Workshop 3
Bariatric follow up in Primary Care
Acknowledgments H Parretti and C Nwosu
WORKBOOK PAGES 21 - 25
Workshop 3
Bariatric follow up in
Primary Care
Aims
To review types and frequency of
bariatric procedures
To understand essential aspects of long
term follow up after bariatric surgery
To explore the role of audit in improving
the quality of routine care in primary care
NICE Guidance CG 189
NICE guidance updated 2014
Expedited assessment for bariatric surgery
if BMI greater than or equal to 35 and
recent onset type 2 DM
Consider bariatric surgery if BMI between
30 and 35 and recent onset diabetes
First line option for those with a BMI more
than 50kg/m2 in whom surgical intervention
is considered appropriate
Lower BMI threshold if of Asian origin
Bariatric surgery types
Types of surgery
Restrictive
• Gastric banding
• Sleeve gastrectomy
Malabsorptive and restrictive
• Gastric bypass
Malabsorptive
• Duodenal switch
Bariatric surgery procedures
9000
8000
7000
6000
5000
4000
3000
2000
1000
2012/2013
2010/2011
2009/2010
2008/2009
2007/2008
2006/2007
2005/2006
2004/2005
2003/2004
2002/2003
2001/2002
2000/2001
0
Data: Health and Social Care Information Centre 2012 and Health Survey England 2012-13
Bariatric surgery procedures
NBSR data 2011-2013
53.9% procedures were gastric bypass
21.4% procedures were gastric band
21.4% procedures were sleeve gastrectomy
0.06% procedures were duodenal switch
Bariatric surgery patient
characteristics
•
•
•
•
•
•
•
Average BMI pre-surgery 48.8kg/m2
26% patients are male (increase from 16% in 2006)
26% women and 45% men have type 2 diabetes presurgery
71.5% women and 73.2% men have some functional
impairment
Average number of co-morbidities 3.4 for women
and 3.7 for men (2.3 and 2.6 in 2006)
54% of men and 41% women have 4 or more comorbidities
Average number of co-morbidities increases with
age and pre-surgery BMI
Funding and follow up
Patients who have had their procedure carried out under
the NHS have follow up within specialist services for the
first 1-2 years post surgery
Patients who have moved area or who undergo a private
procedure are at risk of being lost to specialist follow up
76% procedures NHS funded and 22.6% privately funded
Publicly funded
Privately funded
Gastric band
1879
1686
Gastric bypass
7750
1350
Gastrectomy
2795
819
Duodenal switch
6
5
RCGP Top Tips
These guidelines are aimed at all non-specialist clinicians,
dietitians and nurses to aid management within primary care
or where follow up guidance by the surgical team was not
issued. National guidance not currently available for primary
care
Patchy commissioning of local Tier 3 weight management
services means many post-bariatric surgery patients may be
lost to follow-up, risking nutritional deficiencies and
metabolic complications
New concerns should always trigger referral to a Tier 3
weight management service (if available) or the local
bariatric surgical team for further advice
Top Tip One
Keep a register of bariatric surgery
patients and record the type of procedure
in the register
Note that follow up varies according to the type
of surgery
Top Tip Two
Encourage patients to check their own
weight regularly and to attend an annual
BMI and diet review with a health
professional
Top Tip Three
Arrange emergency admission under the local
surgical team if symptoms of
continuous vomiting
dysphagia
intestinal obstruction (gastric bypass)
severe abdominal pain
Top Tip Four
Continue to review co-morbidities post surgery
such as
diabetes mellitus
hypertension
hypercholesterolaemia
sleep apnoea
mental health
Top Tip Four - A
Medication needs are likely to fall with post-operative
weight loss, but may increase later if weight loss is not
maintained
Keep on QOF diabetes register. Continue routine diabetes
follow-up even if diabetes is in remission
Cardiovascular and metabolic risk factors – continue to
monitor and adjust treatments as required
Patients on CPAP should continue to use their machines
until repeat sleep studies are performed post surgery
Mental health should be reviewed regularly. There is a
higher rate of mental health problems in patients with
severe and complex obesity surgery compared to the
general population
Top Tip Five
Review the patient’s regular medications.
The formulations may need adjusting
post-surgery to allow for changes in bioavailability and swallowing post surgery.
Top Tip Five - A
Review co-morbidity medications post surgery,
such as anti-hypertensives, diabetes
medications, analgesics
Use diuretics with caution due to the increased
risk of hypokalaemia
Replace extended release formulations with
immediate release formulations
Consider pill size – patients may need liquid
formulations or syrups in the immediate postoperative period. Usual medication formulations
should be tolerated by around 6 week post-op
Top Tip Five - B
Avoid bisphosphonates
Avoid NSAIDS: if no alternative use with PPI
Monitor anticoagulants carefully
Psychiatric medications may need increased
or divided doses
Avoid effervescent medications for patients
with gastric bands
Top Tip Six
Bariatric surgery patients require lifelong
annual monitoring blood tests, including
micronutrients.
Encourage patients to attend for their
annual blood tests.
Gastric band patients only require FBC, U&Es and LFTs
annually, or sooner if there are concerns about the band.
Blood test
Surgical procedure
Gastric bypass
Sleeve gastrectomy
Duodenal switch
LFTs
Yes
Yes
Yes
FBC
Yes
Yes
Yes
Ferritin
Yes
Yes
Yes
Folate
Yes
Yes
Yes
Vitamin B12
Yes*
Yes*
Yes*
Calcium
Yes
Yes
Yes
Vitamin D
Yes
Yes
Yes
PTH
Yes
Yes
Yes
Possibly**
No
Yes
Yes
Possibly***
Yes
No***
No***
No***
Vitamin A
Zinc, copper
Selenium
* If patient is having three monthly intramuscular injections of vitamin B12, there may be no need
for annual checks.
**If the patient has a long limbed bypass, symptoms of steatorrhoea or night blindness.
***Measure when concerns
Top Tip Seven
Be aware of potential nutritional deficiencies
that may occur and their signs and symptoms.
If a patient is deficient in one nutrient, then
screen for other deficiencies too.
In particular, consider risk of
anaemia
vitamin D deficiency
protein malnutrition
other vitamin and micronutrient deficiencies.
Top Tip Seven - A
Protein malnutrition
Oedema - need urgent referral back to the bariatric team
Anaemia
iron, folate and vitamin B12 deficiencies all possible.
unexplained anaemia may result from less common causes
such as zinc, copper and selenium deficiencies
some patients may need parenteral iron or blood
transfusions if oral iron does not correct the deficiency
Calcium and vitamin D deficiency
may result in secondary hyperparathyroidism
Vitamin A deficiency
suspect in patients with changes in night vision
patients with steatorrhoea or those who have had a duodenal
switch are at high risk
Top Tip Seven - B
Zinc, copper and selenium
unexplained anaemia, poor wound healing, hair loss,
neutropenia, peripheral neuropathy and cardiomyopathy
ask about OTC supplements and liaise with bariatric unit as
zinc supplements can induce copper deficiency and vice
versa
Thiamine deficiency
suspect in patients with poor intake, persistent regurgitation or
vomiting
may be caused by anastomotic stricture in the early
postoperative phase, food intolerances or an overtight band
start thiamine supplementation immediately and refer urgently
to the local bariatric unit - risk of Wernicke’s encephalopathy
(ophthalmoplegia, ataxia and confusion)
do not give sugary drinks as this may precipitate Wernicke’s
encephalopathy
Top Tip Eight
Ensure the patient is taking the appropriate lifelong
nutritional supplements, 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.
More details: “GP Guidance for the Management of
Nutrition following Bariatric Surgery”
http://www.bomss.org.uk/nutritional-guidelines/
Top Tip Eight - A
Gastric band
No supplements should be needed, but a comprehensive
multivitamin and mineral supplement od, (Sanatogen A to
Z or Forceval) is recommended
Gastric bypass
multivitamin and mineral (OTC comprehensive
multivitamin preparation bd or Forceval od)
3 monthly vitamin B12 injections
calcium and vitamin D (i.e. Adcal D3 Forte, Calceos or
Calcichew D3 Forte) plus additional vitamin D as required
iron (start at 200mg od and monitor as may need to
increase dose), especially for women of menstruating age
Top Tip Eight - B
Sleeve gastrectomy
multivitamin and mineral (OTC comprehensive multivitamin
preparation bd or Forceval od)
3 monthly vitamin B12 injections, if low B12 levels at 12 months
calcium and vitamin D (i.e. Adcal D3 Forte, Calceos or Calcichew
D3 Forte) plus additional vitamin D as required
possibly iron especially for women of menstruating age (dose as
above)
Duodenal switch
As for gastric bypass, but additional fat soluble vitamins (A, D, E
and K) also needed as well as possibly zinc and copper
supplementation. Liaise with specialist local services for advice
regarding these supplements
Top Tip Nine
Discuss contraception – ideally pregnancy
should be avoided for at least 12-18 months
post surgery
LARC of the patient’s choice would be
appropriate.
Avoid OCP due to issues with absorption
Avoid Depo-Provera due to risk of weight gain
Top Tip Ten
If a patient plans to become pregnant after bariatric
surgery alter their nutritional supplements to one
suitable during pregnancy
Inform
the local bariatric unit of patient’s
pregnancy
the obstetric team of the patient’s history of
bariatric surgery
Top Tip Ten - A
Gastric band patients may need their band adjusting
Recommended changes before and during pregnancy are:
Change forceval to a supplement appropriate in pregnancy such as
Pregnacare or Boots Pregnancy Support
If a PPI is needed, omeprazole recommended
Continue vitamin D supplementation according to vitamin D levels
and National Osteoporosis Society guidance
Continue vitamin B12 injections or monitor vitamin B12 levels for
those not receiving vitamin B12 injections (for sleeve gastrectomy
patients)
Iron 200mg od
Folic acid 5mg od
Thanks
Co-Authors
Dr CA Hughes
Ms M O’Kane
Mr S Woodcock
Dr R Pryke
Full guidance available on RCGP Nutrition
Web Pages
References
Duke E and Finer N (2012) Bariatric Surgery: Pre-Operative and Post-Operative Care. Information for
General Practitioners. UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, UK.
Francis R et al, (2013) Vitamin D and Bone Health: A practical clinical guideline for patient
management. National Osteoporosis Society. [Online] Available from:
http://www.nos.org.uk/document.doc?id=1352
Heber D et al, (2010) Endocrine and Nutritional Management of the Post-Bariatric Surgery Patient:
An Endocrine Society Clinical Practice Guideline. Journal of Clinical Endocrinology and Metabolism,
95 (11): 4823-4843.
Mechanick JI et al, (2013) Clinical Practice Guidelines for the Perioperative Nutritional Metabolic and
Nonsurgical Support of the Bariatric Surgery Patient 2013 Update: Cosponsored by American
Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic and
Bariatric Surgery. Obesity 21: S1-S27.
National Institute for Health and Clinical Excellence (NICE) (2006) Obesity: the prevention,
identification, assessment and management of overweight and obesity in adults and children.
National Institute for Health and Clinical Excellence. [Online] Available from:
http://www.nice.org.uk/guidance/CG43.
O’Kane M, Pinkney J, Aasheim ET, Barth JH, Batterham RL and Welbourn R (2014) Management of
nutrition following bariatric surgery: GP guidance. [Online] Available from:
http://www.bomss.org.uk/nutritional-guidelines/.
Thomas CM et al. (2011) Monitoring for and Preventing the Long-term Sequelae of Bariatric Surgery.
Journal of the American Academy of Nurse Practitioners 23: 449-458.
Woodcock S (2014) Primary care management of post operative bariatric patients. British Obesity
and Metabolic Surgery Society. [Online] Available from: insert RCGP nutrition pages URL here
Acknowledgments H Parretti and C Nwosu
WORKBOOK PAGES 26 - 32
Audit Tool for Managing Patients Post
Bariatric Surgery in Primary Care
The Audit Tool Kit
Running the audit of patients 2 years post
bariatric surgery highlights:Importance of coding
Medication and co-morbidity review
Annual blood monitoring
Nutritional Supplements
Annual health check
Concerning symptoms
Pregnancy
In the Real World!
Results of a practice audit in the north of
England showed
Initial audit cycle - no patients had all
their correct bloods done
55% of patients required an intervention
based on blood results
How does your surgery compare?