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Abstract

Bariatric surgery is becoming very common, and most physicians will have contact with bariatric patients. Many aspects to follow-up are not generally known. The objective of this article is to help other physicians understand what follow-up entails to assist them with the care of these patients. It is expected that patients are followed up by the bariatric team for a lifetime, as care is complicated and lifetime follow-up is the key to long-term success.

Keywords: Bariatrics, bariatric surgery, laparoscopic adjustable band, laparoscopic Roux-en-Y gastric bypass, long-term follow-up

Bariatric surgery improves quality of life and comorbid conditions and decreases overall cost of care.1 Patients who undergo surgery will likely increase the length of their lives due to improvement in diabetes and heart disease and decreased risk of cancer.2,3 Long-term bariatric follow-up requires a team approach and attention to several aspects of care. Nutrition is the most important aspect of follow-up to safely maximize weight loss and prevent weight gain. Exercise helps to maintain weight loss. Complications need to be identified early and can result from improper behavior or from surgical complications. Emotional difficulties occur in many patients. This article addresses all these factors.

Two common procedures performed for weight loss are the laparoscopic adjustable gastric band (LAGB) and the laparoscopic Roux-en-Y gastric bypass (LRGBY). The LRGBY constitutes 80% of all bariatric procedures.4,5 The main factors contributing to successful weight loss after bariatric surgery are the patient's ability to make lifestyle changes and to maintain those changes for years to come following the surgery. Success is measured by excess body weight (EBW) loss, which is current body weight minus ideal body weight. After LRGBY, 80% of patients achieve greater than 70% EBW loss over 2 years, and 70% of patients after LAGB achieve greater than 50% EBW loss over 3 years.4 Those who maintain the lifestyle changes for the rest of their lives will maintain the weight loss. These changes include following a healthy well-balanced diet, taking the recommended vitamin supplementation, and exercising regularly (we recommend exercise for 30 minutes 5 d/wk).6 In some patients with severe physical disabilities, physical therapy is often used to help them become mobile and to incorporate the appropriate amount of exercise.6

During the period of weight loss, we closely observe our patients; we then follow up with them once a year. During these visits, patients commonly have appointments with multiple persons on the bariatric team, including the surgeon, a physician extender, a registered dietician, and/or a mental health care provider, depending on the needs of each patient. All team members are important to guide, support, motivate, and educate the patient continuously, so that he/she may achieve a healthy weight after surgery.4 Adjustments to LAGBs are required regularly during the first 2 years to maintain the green zone, at which patients are eating properly and feeling satiated with their small meals for 2 to 3 hours. Later adjustments are needed every year or two as saline slowly leaks out of the band.7,8

In the early postoperative period, the main goals of office visits are to assess proper nutrition status, identify maladaptive eating disorders, evaluate potential complications (internal hernia, ulcers, etc), monitor status of comorbidities, encourage regular exercise, discuss weight loss progress, and check laboratory values (vitamin B1, vitamin B12, magnesium, phosphorous, blood counts, albumin, and a metabolic profile). For most patients, this is a time of emotional turmoil. Family physicians are intimately involved during the period of weight loss because of the changes in comorbidities and in medication requirements.4

During the patient's consultation with the dietician before surgery, specific weight loss goals are calculated based on EBW. After LRGBY, 80% of patients achieve greater than 70% EBW loss over 1218 months, and 70% of patients after LAGB achieve greater than 50% EBW loss over a 2-year period.9 The slower weight loss with LAGB is sometimes discouraging to patients.4

Successful weight loss also results in resolution or improvement of associated comorbidities. Particularly after LRGBY, type 2 diabetes mellitus is commonly in remission on postoperative day 1 and at a bare minimum is better controlled with less medication. Blood pressure should also be managed closely within the first 3 months, but improvements are seen over the first year. Improvement is also noted in arthritis, heart function, and stress incontinence, among other medical problems.4,1014 The use of diuretic agents should be reduced or discontinued in the first month or so to avoid dehydration and electrolyte abnormalities.15,16 The first sign of blood pressure improvement is often light-headedness. Lipid changes are seen during the first year.17 Sleep apnea resolves in most patients, which may require successive sleep studies.

Depression and anxiety medications should be continued for at least the first 6 months. Symptoms of depression should be monitored closely at the first few appointments. Many patients have difficulty with the extreme and instant lifestyle changes. If patients were previous stress eaters and become stressed after surgery, they no longer have the ability to eat for stress relief. After LRGBY, patients usually will experience dumping syndrome (which includes abdominal pain, nausea, vomiting, diarrhea, and diaphoresis). Many patients also experience changes in their social scenes, as many American holidays are centered on a big meal. The way patients interact with the significant people in their lives changes dramatically, and their social structure can be irreparably broken. This is challenging, but patients can overcome these difficult situations with guidance, understanding, and professional counseling when needed.4,18

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Long-term Management of Patients After Weight Loss Surgery

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